Diagnosis: vaginal bleeding.
Treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female who was seen for heavy vaginal bleeding, ovarian cyst, and significant anemia and transferred to an affiliated hospital presumably where she would have access to an inpatients pediatric service. She was admitted as an inpatient status with the "anticipation of a 2-midnight length of stay."
The patient was transfused with 2 units of packed red blood cells (PRBC) and gyn (gynecology) consult was acquired. On the day of admission, the gyn consult determined that the patient's ovarian cyst was of minor concern and could be followed up on as an outpatient and that the bleeding could be managed with oral progesterone therapy.

The inpatient stay was not medically necessary for this patient. The same care could have been just as effectively rendered at a lower level of care. Inpatient admission for two midnights may have been anticipated, but in fact, was not required. On the morning after admission, the patient's blood count was still low and she received two addition units of blood, but her bleeding had significantly slowed to the point that she had not changed her pad overnight. She was stable during the period of observation and discharged home.
According to the Milliman Care Guidelines (MCG) for Anemia (M-35), clinical indications for (inpatient) admission for anemia include hemodynamic instability, active bleeding, altered mental status, cardiac arrhythmias, severe thrombocytopenia, acute renal failure, and signs of cardiac ischemia. In this case, the patient did not have these conditions and was hemodynamically stable.