Digestive system
inpatient hospital

Diagnosis: hematemesis and melena
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a female admitted to the hospital with hematemesis and melena. The patient was seen in the emergency room (ER), released, and then had another episode immediately after discharge and was now admitted. She is not on anticoagulation or anti-platelet agents. On admission, vitals were stable, she was not tachycardic, and the abdomen exam was benign. Admission Hemoglobin (HGB) was 10.2. The patient was started on both intravenous (IV) proton pump inhibitor (PPI) and Carafate with plans for an esophagogastroduodenoscopy (EGD) the following day.

The inpatient hospital admission was not medically necessary. The care provided could have been provided at a lower level of care. The patient is a young, healthy individual. Despite bleeding (not well quantified in the notes), the patient had normal vital signs and a baseline hemoglobin that was only slightly below normal. The patient could have received IV fluids, anti-emetics and a PPI and been safely discharged after a period of observation and a repeat hemoglobin showing stability. The upper endoscopy did not need to be done during the admission and could have been arranged for shortly after discharge.