Diagnosis; Melena.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female with no significant medical history. She presented to the emergency department with epigastric pain, nausea, vomiting with hematemesis, dark bowel movements, and dizziness since the prior day. She had been taking a lot of ibuprofen for ankle pain. Vital signs were unremarkable. Physical examination was notable for soft, nontender, non-distended abdomen. Labs showed elevated white blood cell count of 14.9, elevated blood urea nitrogen of 20, elevated bilirubin of 1.5, elevated aspartate aminotransferase of 65, and elevated alanine aminotransferase of 89. Stool was positive for occult blood. Urinalysis showed large ketones, trace leukocyte esterase, moderate blood, and few bacteria. She was treated with intravenous pantoprazole drip and intravenous fluids. She was made nil per os (NPO).

The inpatient hospital admission is not medically necessary.

In this case, the patient presented with melena, hematemesis, and anemia. However, there was no persistent ongoing gastrointestinal bleeding or sustained tachycardia or hypotension, or ongoing bleeding; her hemoglobin remained stable after initial equilibration. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Proton pump inhibitor therapy was appropriately initiated. Gastroenterology performed an esophagogastroduodenoscopy, which was appropriate, but no active bleeding or high-risk stigmata were found. All of the measures that were undertaken, including monitoring, transfusion, proton pump inhibitor therapy, Gastroenterology consultation, and endoscopy, could have been performed at a lower level of care.