Diagnosis: Vaginal bleeding.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a woman who was admitted to the hospital. She was a smoker and she presented to the emergency department for evaluation of vaginal bleeding and clots. She said that her symptoms started three weeks prior to presentation and her last menstrual period was reportedly at the end of last year. She stated that she was also having breast tenderness and thought that she may have been pregnant. Vital signs showed blood pressure 147/92, hearts heart rate 96, and temperature 97 Fahrenheit. On physical exam, heart was regular, breath sounds were normal and the abdomen had a large liver and spleen but was nontender. Labs showed glucose 99, sodium 139, potassium 4.2, creatinine 0.71, calcium 8.1, white blood cell count (WBC) 10.2, hemoglobin 6.9, and platelets 345. Pregnancy test was negative. The patient was admitted with vaginal bleeding, anemia, and concern for incomplete miscarriage.

The inpatient hospital admission was not medically necessary.

The reason is that the patient had no evidence of hemodynamic instability, tachycardia or low blood pressures, and was not complaining of palpitations or shortness of breath. In addition, there was no physical exam finding of acutely active bleeding or end organ ischemia. Patients with symptomatic anemia and evidence of hemodynamic instability are usually treated at the inpatient level of care, but these findings were not present in the case of this patient.

The patient did not have evidence of active vaginal bleeding, end-organ ischemia, tachycardia, or hemodynamic instability. While she required a blood transfusion, this does not need to be done at the inpatient level of care in hemodynamically stable patients without evidence of acutely active bleeding. The patient could have been cared for at a lower level of care.