Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Deep Vein Thrombosis.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

This is a case of a female admitted for a diagnosis of acute left leg deep vein thrombosis. The patient presented with a chief complaint of left leg pain. Symptoms started one week prior to admission, and she was noted to be wheelchair-bound since having COVID the year prior. Vital signs demonstrated a blood pressure 127/93 millimeters of mercury (mmHg), a pulse of 100 beats per minute (bpm), a temperature of 36.8C., a respiratory rate of 18/minute, and an oxygen saturation of 98%. The physical exam showed no altered mental status or acute distress. There was full range of motion of the joints with left lower extremity edema and tenderness to palpation. An ultrasound of the lower extremity showed an extensive occlusive thrombus of the deep veins of the left leg. Her glucose was 470 with a creatinine of 1.3, platelets of 167,000 and an international normalized ratio (INR) of 1.1. It was felt that the lower extremity deep vein thrombosis was likely from prolonged immobility. The patient was started on Eliquis, and a hematology consult was requested. A computed tomography (CT) of the chest did not show a pulmonary embolism. She was initially treated with Lovenox followed by Eliquis twice daily for 3 to 6 months. She was then discharged.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the medical necessity of admission has been established.
According to Up-to-date, 2022:
"Outpatient therapy - Not all patients who have acute deep vein thrombosis (DVT) need to be admitted to the hospital for systemic anticoagulation. The decision to treat DVT in the outpatient setting should be made in the context of the patient's understanding of the risk-benefit ratio, preferences, and clinical condition. Factors determining who may be considered for outpatient therapy are not well defined. However, several randomized trials and meta-analyses that have compared outpatient therapy with low molecular weight (LMW) Heparin to inpatient therapy with intravenous (IV) unfractionated Heparin (UFH) suggest that treatment at home with LMW Heparin is safe and effective in select patients. Anticoagulant therapy should not be delayed while the decision is being made to treat the patient at home.
When considering outpatient administration of LMW Heparin, patient selection is critical:
Outpatient therapy can be considered when patients have all of the following features :
1) Hemodynamically stability.
2) A low risk of bleeding.
3) No renal insufficiency.
4) A practical system in place at home for the administration and surveillance of anticoagulant therapy (e.g., good living conditions, caregiver support, phone access, understanding and ability to return to the hospital should deterioration occur).

Outpatient therapy is not appropriate in patients with:
1)Massive DVT (e.g., iliofemoral DVT, phlegmasia cerulea dolens).
2)Concurrent symptomatic pulmonary embolism (PE).
3)High risk of bleeding on anticoagulant therapy.
4)Comorbid conditions or other factors that warrant in-hospital care."
Although the patient was diagnosed with a deep vein thrombosis and was hemodynamically stable, she had complicating factors including acute renal insufficiency and a massive deep vein thrombosis extending up into the iliofemoral venous system. There was also involvement in the left common femoral vein and greater saphenous vein. Given these findings, medical literature does not support outpatient therapy for the initial treatment of DVT. Therefore, the medical necessity of the admission has been established.