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202108-140888

2021

Empire Healthchoice Assurance Inc.

Indemnity

Digestive System/ Gastrointestinal

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis: melena

Treatment: inpatient stay

The insurer is denied coverage for inpatient stay

The denial is overturned.

This male patient has a history of lupus anticoagulant syndrome.

Clinical indications for admission for Upper Gastrointestinal Bleeding are listed in Milliman Care Guidelines (MCG) M-180. Ongoing active bleeding, such as a decreasing hematocrit, is an indication for admission. In addition, a peptic ulcer with a high-risk endoscopic feature such as a visible vessel, is also an indication for admission. The patient met the criteria for admission. This patient had a dropping hemoglobin and an ulcer with a visible vessel.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for inpatient stay is overturned. The medical necessity is substantiated.

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