Diagnosis: Symptomatic microcytic anemia.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of anemia, fibroids, methadone-dependency, and hypertension (HTN) and was admitted with complaints of (c/o) lightheadedness and vertigo without respiratory distress, pale skin. Her vital signs on admission were unremarkable, with a normal blood pressure (BP) and pulse. The physical exam was notable for non-ill appearing, non-toxic appearing. Lab work showed a hemoglobin of 4.4 and hematocrit of 15.6. The patient was diagnosed with symptomatic microcytic anemia and treated with intravenous fluids (IVF) and blood transfusion times (x) 3. The patient was discharged in stable condition. At issue is whether the inpatient stay was medically necessary.

The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with c/o lightheadedness and vertigo without respiratory distress. The patient was found to have a low hemoglobin with a known history of uterine bleeding with fibroids, but had no history of hematochezia, hematemesis, or melena. The patient received three units of packed red blood cells (PRBCs), symptomatically improved, and was discharged home in stable condition. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, or bright red blood per rectum (BRBPR), coagulopathy, or known esophageal varices. This patient could have been safely observed and received diagnostic work-up, consultation and transfusion at a lower level of care.
Regarding the Milliman Care Criteria, the patient did not have hemodynamic instability, active hemolysis, active bleeding that cannot be controlled at a lower level of care, severe or persistent altered mental status (AMS), recurrent syncope, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low-platelet count, acute renal failure, heart failure, chest pain, myocardial ischemia, dyspnea not responsive to treatment, or need for pulmonary artery catheter monitoring or urgent inpatient surgery.