Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep vein thrombosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This case involves an adult female who presented to the emergency department with left calf/leg pain following a visit to urgent care.  She was unable to walk and wanted to be seen for deep vein thrombosis (DVT) studies.  Records noted the patient was an everyday smoker of one-quarter packs/day for fifteen years.  The patient reported some mild numbness in the leg coinciding with the swelling.  The swelling had been occurring for approximately one week and she was sent by urgent care for a DVT rule out.  On examination, the patient had uniform swelling of the left lower extremity with tenderness overlying the inner thigh and calf.  A bedside ultrasound was performed showing DVT in the femoral vein proximally with extension distally in the leg.  The patient reported having shortness of breath for one week although lungs were clear bilaterally.  She was placed on cardiac monitoring and an intravenous catheter was placed.  Electrocardiogram (EKG) noted sinus bradycardia at 46 beats per minute with no acute changes.  The patient was admitted for probable acute on chronic DVT of the left femoral vein with hypercalcemia requiring intravenous hydration.  The patient was started on Lovenox subcutaneous every twelve hours. The sinus bradycardia was likely due to methadone given the patient's history of substance abuse.  She was positive for claudication and leg swelling along with left leg pain and tenderness.   Elevated blood pressure was likely due to pain.  Plans were to monitor the patient's blood pressure and start a two gram sodium diet.  She was obesity class I without serious comorbid conditions and counseled on diet and exercise. The treating physicians clinical impression was emergently concerning for acute on chronic deep vein thrombosis, hypercalcemia, hyperparathyroidism, vitamin D toxicity, cystitis, urinary tract infection, methadone induced bradycardia, hypothyroidism, substance use, failure of outpatient anticoagulation, varicose veins, peripheral arterial disease, peripheral vascular disease, and hypertension.  

According to the Milliman Care Guidelines, inpatient admission is typically indicated for patients with deep vein thrombosis of the lower extremities for up to four days.  Patients meeting this criterion include those who require inpatient anticoagulation administration such as in the case of this patient who failed to respond effectively to at-home anticoagulation use.  The patient was confirmed as having deep vein thrombosis affecting the left lower extremity.  She had multiple comorbidities affecting her health that placed her at an increased risk for an adverse event.  Based upon the totality of information submitted regarding the patient's current health status and evidence of the deep vein thrombosis with a one-week history of shortness of breath and comorbid conditions, the inpatient stay was appropriate and within the standard of care.  As such, the inpatient admission was medically necessary.

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.