Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Vein Thrombosis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a  male with a history of deep vein thrombosis (DVT) (on Eliquis) who presented to the hospital with right leg swelling. He was evaluated in the outpatient setting with noted right leg edema, and it was confirmed that there was a second DVT in the gastrocnemius vein by an outpatient doppler ultrasound. He was referred to the emergency department to obtain a computed tomography (CT) scan of the abdomen and to be evaluated by hematology. The patient denies any trauma, prolonged immobility, or palpitations. The CT of the abdomen and pelvis completed in the ED showed no intra-abdominal pathology, but no vasculature was mentioned.

His vital signs were stable. The examination was unremarkable except for the right leg, which was wrapped by a dressing and it had a larger diameter than the left, with plus 1 pitting edema. His hemoglobin was 9.6 and his international normalized ratio (INR) was 1.84. The medical team started the patient on a Heparin drip and ordered a hypercoagulable workup. They also consulted hematology to evaluate the patient.

Over the next 24 hours, the patient was stable. The decision was made to transition to a different direct oral anticoagulant and to complete a hypercoagulable workup as an outpatient. The patient's leg swelling improved. However, the decision was changed to the bridge and treat with Warfarin for six months. Vascular surgery recommended repeating the CT scan with contrast.

The patient's vital signs continued to be stable. The patient remained in the hospital and was reassessed. His INR was subtherapeutic. He was encouraged to ambulate as tolerated. The plan was unchanged, and his INR was 1.64. The INR increased to 1.78 by the next day. The patient was discharged on Coumadin therapy.

Yes, in its determination of medical necessity, the health plan acted reasonably, with sound medical judgment, and in the patient's best interest.

The inpatient hospital admission was not medically necessary. The patient developed a recurrent DVT while anticoagulated with a direct oral anticoagulant. He was switched over to Heparin and bridged to Warfarin. The medical team does not mention contraindications to using Enoxaparin or Fondaparinux as a bridging therapy to warfarin, which can be accomplished in the outpatient setting. There was no evidence of a pulmonary embolism, with a normal heart rate and lack of hypoxemia.
There were no clinical contraindications, to using Enoxaparin or Fondaparinux in this clinical setting, such as recent spinal surgery, mechanical aortic valve, or intracranial bleed. There was no reported history of gastrointestinal (GI) bleeding that would require ongoing monitoring. A hypercoagulable workup can be completed in an outpatient setting. The patient was hemodynamically stable. He did not have a threatened limb or require a mechanical thrombectomy. Therefore, indications for an inpatient admission are not satisfied.

The health plans determination of medical necessity is upheld in whole.