Diagnosis: Blood Disorder/Anemia.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary.
The health plan's determination is overturned.

The patient is a female with a history of metastatic poorly differentiated carcinoma who is status post chemotherapy with Carboplatin/Paclitaxel, spinal cord radiation and surgical fixation for spinal cord compression and was recently started on Pembrolizumab. She presented to the hospital with vaginal bleeding x 1 week from a vaginal metastasis and was found to have a hemoglobin of < 5. On admission, she was noted to be tachycardic to the 130s beats per minute and with a 2-liter oxygen requirement. She was transfused with 3 units of packed red blood cells in the observation unit and was admitted after it was clear that she needed ongoing transfusion support. The patient was seen by radiation oncology who delivered several fractions of radiation to the vaginal mass to slow down bleeding. She was also seen by pulmonology for a new onset of hypoxia and was evaluated for Pembrolizumab pneumonitis. The patient was discharged home after blood counts had stabilized.
At issue is the medical necessity for the inpatient admission.

The health plan's determination of medical necessity is overturned, in whole.

Yes, inpatient admission was medically necessary for refractory bleeding secondary to metastatic carcinoma requiring repeat transfusions and palliative radiation.
The patient is a female with metastatic carcinoma who presented with life-threatening bleeding due to a metastatic lesion in the vagina. She presented with signs of class 2 hemorrhagic shock with an elevated heart rate and respiratory rate [1]. The patient was initially appropriately placed in observation for the purposes of a blood transfusion, but when it became clear she would require more intensive interventions to stop the bleeding, she was admitted to the hospital. For patients presenting with malignant bleeding, radiation is often used to slow or stop bleeding, and this is often administered in the inpatient setting in cases of active bleeding [2].