202109-141640
2021
Empire Healthchoice Assurance Inc.
Indemnity
Blood Disorder
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Anemia.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission. The denial is upheld.
The patient has a past medical history of gastroesophageal reflux disease, immune compromise with medication non-compliance. The patient was sent to the emergency department from presurgical testing for abnormal lab studies. She was status post presurgical testing. She was scheduled for eye surgery. She denied dizziness, chest pain, dyspnea. The patient reported frequently taking Aleve/Advil for recent ear pain. She denied any rectal bleeding, melena or hematemesis. The patient's blood pressure was 176/72. Exam in emergency department (ED) noted brown stool guaiac positive. Exam otherwise unremarkable. Labs showed a potassium (K+ [potassium]) of 3.1, creatinine of 0.93, blood urea nitrogen (BUN) 18, hematocrit (Hct) 23. Computed tomography (CT) of abdomen/pelvis revealed no acute findings. The patient was transfused with 2 units of blood. The Hct was 37. The patient was given oral potassium and requested intravenous potassium as she did not like the taste. The patient was admitted to the medical/surgical unit for evaluation of anemia. The patient underwent a gastrointestinal evaluation and chose to leave Against Medical Advice.
The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.
The inpatient admission Hospital was not considered medically necessary for this patient.
The patient was found to be anemic and mildly hypokalemic during presurgical testing for eye surgery. She was hemodynamically stable with no evidence of active bleeding. She had no symptoms related to the anemia or hypokalemia. Transfusion could have been done during a period of observation, and in fact by the morning her Hct was 37. A potassium (K+) of 3.1 does not require acute intervention and is managed as an outpatient (OP)
The health plan acted reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.