Diagnosis: Blood Disorder-Anemia
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

This case involves a female patient with a history of gastric cancer status post gastrectomy many years before this presentation, who presented to the hospital after outpatient lab testing revealed hemoglobin of 5. The patient has a history of anemia, with limited blood draws in the outpatient setting to prevent further phlebotomy, and therefore did not appear to know her baseline hemoglobin level. The last endoscopic evaluation with esophagogastroduodenoscopy (EGD) and colonoscopy was reportedly normal. The patient denied any visual bleeding episodes. She felt tired and short of breath for prolonged periods of time. She experienced some cramping in the extremities. The patient reported diarrhea after food intake but otherwise no constitutional symptoms. On arrival in the emergency department (ED), the hemoglobin was confirmed at 6.4, and she was given 1 unit of blood. Vital signs appeared stable. On examination, the patient's cardiopulmonary exam was unremarkable. The abdomen was soft and nontender to palpation. The electrolytes and renal function remained stable. The liver function tests (LFTs) were normal as well. The patient was admitted to the hospital with a principal diagnosis of anemia. The fecal occult blood test was negative. The medical team ordered a computed tomography (CT) angiogram of the abdomen and pelvis and established the goal for hemoglobin greater than 7. This suspected the patient is poorly absorbing iron and B12 due to the gastrectomy as the primary cause of the anemia. They also ordered an echocardiogram because the patient was experiencing dyspnea, although the low hemoglobin likely explains the symptoms.
The following day, the patient's hemoglobin was rechecked and was 8 grams per deciliter (g/dL). The CT scan of the abdomen and pelvis showed no active bleeding. The echocardiogram showed a normal ejection fraction with no wall motion abnormalities. The patient was deemed medically stable for discharge. She was prescribed iron tablets and scheduled for an outpatient follow-up to recheck her hemoglobin in 1 week.

No. Inpatient hospitalization is not warranted in this case. There is no clinical indication for admission to an inpatient level of care in the patient with chronic anemia, who required a blood transfusion and was stable. There is no hemodynamic instability. The fecal occult blood test is negative, the patient endorsed no occult bleeding, and the CT angiogram failed to demonstrate an active bleeding source. The patient has undergone gastrectomy and is likely chronically malabsorbing iron, hence the iron deficiency anemia. A lower level of care setting is the perfect setting for this type of presentation, rapid work-up, and subsequent discharge within 24 hours.