Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Other-Pulmonary embolus/DVT (deep venous thrombosis).
Treatment: Inpatient hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

The patient  was initially admitted for concerns of shortness of breath secondary to a recurrent pulmonary embolism. Pertinent history included a pulmonary embolism with anticoagulation discontinued, chronic kidney disease stage 3 (baseline serum creatinine 1.7), and hypertension.  Initial vital signs revealed a temperature of 99.1Fahrenheit, heart rate  103, blood pressure 145/75, respiratory rate 18, peripheral capillary oxygen saturation (SpO2) 96% on room air. Initial serology revealed a white blood cell count 5.7, hemoglobin 10.9, platelets 195, sodium147, potassium 3.7, blood urea nitrogen  18, Creatinine 1.7, Glucose 98, brain (or B-type) natriuretic peptide (BNP) 5.1, Troponin 0.01, and D-dimer 3.72. Rapid flu and COVID-19 tests were negative. An electrocardiogram (EKG) revealed normal sinus rhythm without acute ischemic changes. Chest radiograph did not reveal a focal infiltrate but did note perihilar interstitial prominence. The admitting physician had an impression of shortness breath likely due to a recurrent pulmonary embolism (PE). Treatment plan included a heparin infusion, duplex ultrasound of the bilateral extremities, EKG, echocardiogram, and a V/Q (ventilation/perfusion)  scan.  Duplex ultrasound of the lower extremities revealed a thrombus in the right gastrocnemius vein. Treatment plan noted Lovenox every 12 hours with plans to transition to a direct oral anticoagulant at discharge. V/Q lung scan revealed a partially mismatched defect within the entire lingula consistent with a pulmonary embolism. 
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. The patient had a pulmonary embolism severity index score of 81, consistent with Class II, and a simplified pulmonary embolism severity index score of 0. Both would be considered low risk. A pragmatic evaluation was published in the Journal of Thrombosis and Hemostasis which investigated the safety of treating patients in the outpatient setting who presented acutely with symptomatic pulmonary embolism. The conclusion was that outpatient management of uncomplicated pulmonary embolism seems safe and effective in the absence of other indications for hospital admission.[2]
In this particular situation, the patient did not have hemodynamic instability, vital sign derangements, hypoxia, or need for parenteral narcotics. In addition, the patient did not have hypoxemia, history of chronic cardiopulmonary disease, cardiac arrhythmias of immediate concern, right ventricular dysfunction, or strain, positive cardiac biomarker. The patient was not felt to be high risk for acute complications of anticoagulation as the patient did not have bleeding before anticoagulation, recent surgery that increases risk of catastrophic bleeding, recent gastrointestinal bleeding, recent ischemic stroke, history of bleeding with anticoagulation, or active substance abuse. Lastly, the patient did not have limb-threatening thrombosis, requirement for thrombolysis, indication for vena cava filter placement, pregnancy, or contraindications to outpatient use of medication with rapid anticoagulation effect. The patient was appropriately admitted and observed in the hospital given the presenting complaint of dyspnea and the clinical concern for a pulmonary embolism. Following this care, the patient no longer had dyspnea, nor did he have hemodynamic instability, hypoxemia, tachypnea, evidence of significant bleeding, or any significant findings discovered during the comprehensive evaluation that would require an inpatient level of care.[4]