Diagnosis: Anemia
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female who initially was directed to the emergency department by her primary care physician for concerns of anemia. Review of symptoms was negative for signs of bleeding. Pertinent history included erosive gastropathy and duodenal arteriovenous malformations (AVM), chronic kidney disease, deep vein thrombosis on Eliquis, congestive heart failure, cerebrovascular accident (CVA) with residual aphasia, hypertension, and diabetes mellitus.

The inpatient level of care was not medically necessary. In this particular situation, the patient was directed to the emergency department following an abnormal blood draw in the outpatient setting. The attending physician documented asymptomatic acute on chronic anemia without a baseline provided. Treatment plan included transfusion of packed red blood cells. Gastroenterology consultation was obtained, who documented no signs of overt gastrointestinal bleeding or indication for urgent endoscopic intervention. In addition to being hemodynamically stable, the patient did not have documented active hemolysis, active bleeding, altered mental status, syncope, cardiac arrhythmia of immediate concern, decompensated heart failure, or other severe signs or symptoms secondary to anemia.