Diagnosis: Rectal Bleeding, Anemia

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a patient who has a history of anemia and hemoglobin as low as 5.4. She presented to the Emergency Department (ED) with complaints of bloody diarrhea. Her vital signs were stable, although she had a mild tachycardia. The abdominal exam was benign. A laboratory work-up was performed that revealed her hemoglobin was 4.7. Her stool was tested and was positive for blood. Gastroenterology consulted on the patient with recommendations for endoscopic testing. She received a blood transfusion with repeat hemoglobin of 6.8. The patient refused further blood transfusions.

Clinical indications for admission for Lower Gastrointestinal Bleeding (M-182) include ongoing active bleeding, failure to control bleeding after a colonoscopy, coagulopathy, hemodynamic instability, severe thrombocytopenia and anemia with signs of cardiac ischemia. The patient did not have these conditions. At the time of admission she was found to have brown stool that was only faintly heme positive.

This patient had rectal bleeding and anemia. She was not actively bleeding in the hospital. The hemoglobin improved after a transfusion. She was stable to have received the transfusion with observation status. Afterwards, a repeat of the endoscopic testing could have been performed on an outpatient basis. She did not meet MCG criteria for admission for lower gastrointestinal bleeding.

The healthcare plan acted reasonably and with sound medical judgment.

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.