Diagnosis: Gastrointestinal bleed

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult patient with portal vein thrombosis secondary to Janus kinase 2 (JAK 2) mutation, splenomegaly post portal vein stent placement with thrombus (noncompliant with anticoagulation), and asthma who presented to Emergency Department (ED) with melena x2days and hematemesis x1day. The patient was admitted for further treatment of upper gastrointestinal (GI) bleed (concerning for esophageal varices) including intravenous (IV) proton pump hnhibitor (PPI), Octreotide and further evaluation with upper endoscopy. On the evening of admission, the patient left against medical advice.

Acute upper GI bleed is considered a medical emergency with a mortality rate for non-variceal bleed in the range of 10% and 20% for variceal with higher rebleeding rate and hemorrhagic shock (1). Correct establishment of support measures and specific therapy is associated with decreased mortality. One study demonstrated a reduction of up 28% on in-hospital mortality with the use of accurate therapies (including high dose IV PPI, and vasoactive drugs) (2). A recent American College of Gastroenterology (ACG) Clinical Guideline for upper gastrointestinal (UGI) and Ulcer Bleeding was published in 2021 suggesting the use of a risk assessment tool to identify patients who may be discharged home from the ED with UGI should be based on Glasgow-Blatchford score (GBS) 0-1. Patients with greater than or equal to 2 GBS should be admitted to the hospital for further treatment and observation (3).

In the case of this patient, as per the indications above (UGI bleed with concern for variceal etiology), and GBS greater than 2, inpatient care for close observation and IV medications was warranted.

The inpatient admission for IV medications and close observation was medically necessary in a patient with UGI bleed and multiple co-morbidities with high concern for a possible variceal bleed that carries a high mortality rate. Managing this patient as an outpatient is not an option.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient admission is substantiated