Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Vein Thrombosis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

The patient presented to the emergency department with concerns for left leg pain and swelling. Pertinent history included ulcerative colitis on prednisone with recent gastrointestinal bleeding two weeks prior to presentation. Initial vital signs revealed a temperature of 97.9 degrees Fahrenheit (F), heart rate (HR) 73, blood pressure (BP) 117/76, respiratory rate (RR) 17, and peripheral capillary oxygen saturation (SpO2) 100% on room air. The initial examination documented left lower extremity edema without neurovascular compromise. Initial laboratory testing revealed a markedly elevate D-dimer, white blood cell count (WBC) of 15.2, hemoglobin (Hgb) 13.7, platelets (Plt) 243, international normalized ratio (INR) 1.0, sodium (Na) 134, potassium (K) 4.0, blood urea nitrogen (BUN) 13.1, and creatinine (Cr) 0.8. A duplex ultrasound revealed a preliminary report of a deep vein thrombosis and the patient underwent an "in-house" transfer to another facility. Percocet and Lovenox 1 milligram per kilogram (mg/kg) were administered. Repeat laboratory testing while in the emergency department revealed a Na of 127, BUN 17, Cr 0.7. The maximum temperature was 101.9 degrees Fahrenheit (F). The patient was admitted with an impression of a deep vein thrombosis of the left lower extremity. The treatment plan included a computed tomography (CT) venogram of left leg to confirm the diagnosis and evaluate extent of propagation as well as therapeutic Lovenox. Due to recent gastrointestinal bleeding, there was concern for a relative contraindication to anticoagulation. The CT angiogram revealed a deep vein thrombosis involving the common femoral to the popliteal veins. The treatment plan was updated to include inferior vena cava (IVC) filter evaluation and multiple consultations to discuss anticoagulation strategies.
A gastroenterology consultation was obtained and noted no signs of active bleeding or an absolute contraindication to anticoagulation. A hematology consultation was obtained with an impression of acute lower extremity deep vein thrombosis. Recommendations included continuation of therapeutic Lovenox. There was no significant clinical change. Left lower extremity pain persisted and was treated with oral opiates. A pain management consultation was obtained and recommended continued oral Percocet for analgesia. A discharge summary was placed. The patient was discharged on Eliquis.

Yes. Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was medically necessary for the entire admission.
Wilbur et al. note that pulmonary embolism and deep venous thrombosis are the two most important manifestations of venous thromboembolism (VTE), which is the third most common life-threatening cardiovascular disease in the United States. Anticoagulation is the mainstay of venous thromboembolism (VTE) treatment. They state that most patients with deep venous thrombosis or low-risk pulmonary embolism can be treated in the outpatient setting with low-molecular-weight heparin and a vitamin K antagonist (warfarin) or direct-acting oral anticoagulants. Unfractionated heparin is used if a patient is hemodynamically unstable or has severe renal insufficiency, high bleeding risk, hemodynamic instability, or morbid obesity. Direct-acting oral anticoagulants are an alternative; however, concerns include cost and use of reversing agents (currently available only for dabigatran, although others are in development). If warfarin, dabigatran, or edoxaban is used, low-molecular-weight or unfractionated heparin must be administered concomitantly for at least five days and, in the case of warfarin, until the international normalized ratio becomes therapeutic for 24 hours. Hemodynamically unstable patients with a low bleeding risk may benefit from thrombolytic therapy.[1]
In this particular situation, the patient had a history of ulcerative colitis with a recent flare manifested as hematochezia who presented with a left lower extremity deep vein thrombosis and associated left leg pain. Due to a concern for intestinal bleeding, an inferior vena cava filter placement was discussed with the multiple consultations obtained. Therapeutic anticoagulation was initiated and continued beyond the observation time frame while the topic of an IVC filter was addressed. The patient did not have evidence of a recurrent gastrointestinal bleed. Therefore, clinical indications for admission to inpatient care were met due to recent gastrointestinal bleeding within the last several weeks prior to presentation as well as increased risk of gastrointestinal bleed.[2] Evaluation and management could not have safely been performed at lower level of care.