Diagnosis: Blood Disorder/Anemia Treatment: Inpatient Hospital The health plan denied the requested inpatient hospital stay due to the lack of medical necessity. The health plan's determination is upheld. The patient is a male with a medical history of hypertension, nephrotic syndrome, gout, and benign prostatic hyperplasia. He presented to the emergency department with hematochezia, constipation, dyschezia, fatigue, and unintentional weight loss of 18 pounds over 6 months. Vital signs were notable for tachycardia with heart rate of 117/minute. Physical examination was notable for soft, nontender, nondistended abdomen, and rectal exam negative for external hemorrhoids and melena. Labs showed low hemoglobin of 6.9 and a hematocrit of 22.9%, an elevated platelet count of 630, and an elevated neutrophil fraction of 85%. Stool was trace guaiac positive. A chest x-ray showed no acute cardiac or pulmonary pathology. He was transfused with two units of packed red blood cells. He was discharged with a plan for primary care, gastroenterology, and colorectal surgery follow-up. The health plan's determination of medical necessity is upheld, in whole. No, the medical necessity of the inpatient level of care is not supported. In this case, the patient presented with symptomatic anemia, concerning for gastrointestinal bleeding; however, there was no sustained tachycardia or hypotension, and no significant visible ongoing gastrointestinal bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-5]. His blood count responded to transfusion and remained stable. Esophagogastroduodenoscopy and colonoscopy were warranted and performed, with confirmation of rectal cancer as a cause for hematochezia and anemia [1-5]. All the measures that were undertaken, including monitoring, blood transfusion, labs, specialist consultations, imaging, esophagogastroduodenoscopy, and colonoscopy, could have been performed without the inpatient level of care, at the observation level of care [2-5].

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