Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary embolism

Treatment: Acute inpatient admission

The insurer denied coverage for the acute inpatient admission.

The denial is upheld. 

This is a male patient with a past medical history of pulmonary embolism, nephrotic syndrome, hypertension (HTN), hyperlipidemia (HLD) who presented to the hospital with complaints of mid-upper back pain radiating to the front of his chest for 2 days. The patient reported that this symptom felt similar to the pain he felt when he had pulmonary embolism in the past. The patient described the pain as pleuritic. The patient was prescribed Xarelto but the patient has not been compliant with anti-coagulation. The patient has not being following up with Hematology, as well. The patient's vital signs at hospital presentation were: temperature 99.6, heart rate 93, respiratory rate 20, blood pressure165/99, and oxygen saturation 98% on room air. 

On physical exam, the patient was not in acute distress, and his lungs were clear. The patient's cardiovascular and abdominal exams were unremarkable. The patient was alert and oriented. The patient had a non-focal neurological exam. The patient's computed tomography (CT) pulmonary angiography showed bilateral pulmonary embolism. There was no CT evidence of right heart strain. The patient was started on Lovenox therapeutic dose. The patient's maintenance blood pressure medications and nephrotic syndrome medications were also started. The patient was admitted to the hospital for treatment of bilateral pulmonary embolism. 

The patient had an echocardiogram, which revealed normal left ventricular ejection fraction (LVEF) and no evidence of right heart strain. The patient remained stable after admission. By day 2 of admission, the patient's vital signs showed: temperature 97.6, heart rate 72, respiratory rate 18, blood pressure 147/77, and oxygen saturation 98% on room air. The patient's pleuritic chest pain was still present but improved with pain medication. The patient's physical exam remained unremarkable. The patient was seen by hematology who recommended that the patient starts on direct oral anticoagulants (DOACS) at discharge. There were no other recommendations other than outpatient follow-up. The patient was ambulating and was restarted on his oral medications. The patient's pulmonary embolism was likely chronic. The patient was afebrile and hemodynamically stable, not in acute distress, not hypoxic and was tolerating oral intake. There was no evidence of right heart strain noted on the patient's electrocardiogram (EKG), CT, or echocardiogram. 

Based on the review of the medical record and literature, this patient did not need acute hospitalization. The patient could have been placed on observation status while diagnostic testing and treatment were initiated. Observation status could be for up to 48 hours.

Pulmonary embolism was not a new diagnosis for this patient who had a history of pulmonary embolism and has not been compliant with his anticoagulation medication. The patient's symptoms were triggered by non-compliance with medication. It was a provoked pulmonary embolism. Moreover, this patient was afebrile, hemodynamically stable, and not hypoxic. The patient remained stable after admission. The patient was medically stable by day 2 of admission to be discharged home on direct oral anticoagulant (DOAC) as recommended by hematology. The patient could have been followed closely in the outpatient setting. Thus, acute inpatient admission was not medically necessary for this patient. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for acute inpatient admission is not substantiated. The insurer's denial should be upheld.