Diagnosis: Idiopathic thrombocytopenia purpura
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This patient presented with a history of rash and was found to have thrombocytopenia. She was noted to have bruising, petechiae and nose and mouth bleeding. Her hemoglobin was 12.7 and white blood cell count was normal. She had platelets count of 9000 and was diagnosed with idiopathic thrombocytopenia purpura (ITP) and was admitted to the hospital. She received a dose of intravenous immunoglobulin (IVIG) and was discharged home.

The hospital admission is not considered medically necessary for this patient. The member had petechiae and bruising with a low platelet count. All other cell lines were normal. The patient was diagnosed with ITP and treated with IVIG. There was no evidence of severe bleeding, fever or other comorbidities that required acute care hospitalization. The patient could have been safely managed at a lower level of care where IVIG could be safely given followed by outpatient care with a pediatric hematologist.

"Treatment should always be tailored to the patient because many factors contribute to treatment decisions. Impacting management decisions are the extent of bleeding, age, comorbidities predisposing to bleeding, complications of specific therapies, activity and lifestyle, fatigue, tolerance of side effects, need for interventions with a bleeding risk, accessibility of care, patient expectations, patient worry or anxiety, and patient need for non-ITP medications that may create a bleeding risk. Patient preference must be considered when discussing treatment options." (Provan et al., 2019)

"Management of children with newly diagnosed immune thrombocytopenia (ITP) consists of careful observation or immunomodulatory treatment. Observational studies suggest a lower risk for chronic ITP in children after IVIG treatment." (Heitink-Pollé et al., 2018)

"Conclusion: The total platelet count rises higher in early and late phases with IVIG than Anti-D, but in long term it is higher with methylprednisolone. Additionally, IVIG causes less adverse effects than Anti-D and corticosteroids." (Acero-Garcés et al., 2020)

"Conclusions and relevance: We demonstrated a significant practice change in the management of newly diagnosed ITP at a pediatric care tertiary care hospital in the United States surrounding revision of the American Society of Hematology (ASH) management guidelines for childhood ITP. Our experience supports adoption of observation alone for a proportion of patients with newly diagnosed childhood ITP. This form of management did not lead to an increase in later treatment or an increase in delayed bleeding symptoms." (Schultz et al., 2016)

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.