Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis (DVT)

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

This case involves a male who presented to the emergency department with a 3-day history of left eye swelling, soreness, and pain. He had a past medical history significant for hypertension, asthma, gastric ulcer, and deep vein thrombosis. Records stated that he was not on anticoagulants, and he had been sent from the urgent care center to rule out left lower extremity deep vein thrombosis. During his examination, he had notable left thigh swelling with erythema on the medial aspect in addition to tenderness and warmth to the touch. The venous duplex report revealed occlusive and nonocclusive thrombus that extended from the common femoral vein to the posterior tibial vein.  Computed tomography angiography of the pulmonary arteries showed findings consistent with pulmonary emboli.  The patient was given an intravenous heparin bolus in the emergency department and started on heparin infusion. He was admitted for continued heparin infusion and close monitoring.  

The Milliman care guidelines state that clinical indications for admission to inpatient care for patients who have deep venous thrombosis of lower extremities includes patients who are at high risk for acute complications upon initiation of anticoagulation as indicated by 1 or more of the following to include bleeding before anticoagulation, recent surgery, recent GI (gastrointestinal) bleeding, history of intracranial bleeding, history of active bleeding when anticoagulated, coagulopathy, or other risk factors thought to place the patient at high risk such that ability to rapidly reverse anticoagulation is necessary.  Additionally, patients who have a limb threatening thrombosis, thrombolysis or pharmacomechanical thrombectomy needed, when inferior vena cava filter placement is appropriate, when inpatient anticoagulation is needed, if the patient is pregnant and has a planned delivery and is 37 or more weeks gestation, is in severe pain requiring acute inpatient management, as significant bleeding, or allergic, autoimmune, or coagulopathic reaction in response to anticoagulation, if there is a personal or family history of significant allergic, autoimmune, or coagulopathic reaction in response to anticoagulation that requires monitoring beyond observation care, or the patient has a personal or family history of significant bleeding tendency or bleeding disorder that requires monitoring beyond observation care.  

The records provided for the review did not provide supporting information indicating that the patient cannot be treated on an observational or outpatient basis. While it is noted that he was found to have deep vein thrombosis in the left lower extremity along with pulmonary emboli, the heparin bolus and heparin infusions could have been administered at a lower level of care and the patient could have been treated effectively without the need for inpatient management. As such, the prior determination is upheld.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.