Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is a patient who presented to the emergency department (ED) with calf pain and was found to have a deep vein thrombosis (DVT). The patient was admitted, had multiple tests done, and was placed on Eliquis. Genecology service removed an implant; the patient was discharged three days later. The request is for inpatient admission, which is under review.

An individual with a DVT/pulmonary embolism (PE), who is hemodynamically stable would be expected to be safe for discharge within 24-48 hours. The patient was initiated on apixaban, an oral anticoagulant that required no bridging and no parenteral therapy. Apixaban does not require acute level care for initiation or titration. Further, the removal of the intrauterine devices (IUD) should have occurred within the first 24 hours and does not require acute level care, as it can be done in an outpatient setting.

There is no reason to perform thrombophilia testing during an acute DVT, as it does not alter management and several of the tests are affected by anticoagulation and the DVT.

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

Per Salvi, A., et al., (2020), "The management of DVT should be as outpatients except in presence of one of them: ongoing bleeding or high bleeding risk (Venous thromboembolism (VTE) BLEED risk score); severe renal failure; metastatic cancer, massive DVT, involving iliac femoral vein, caval vein or severely symptomatic patients (phlegmasia dolens); and/or inadequate home-care setting."

Per Waheed, S. M., Kudaravalli, P., & Hotwagner, D. T. (2023), "Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of developing post-thrombotic syndrome.

The cornerstone of treatment is anticoagulation. National Institute for Health and Care Excellence (NICE) guidelines only recommend treating proximal DVT (not distal) and those with pulmonary emboli. In each patient, the risks of anticoagulation need to be weighed against the benefits.

Treatment for DVT should be addressed mainly according to the underlying causality of DVT as follows:

The preferred anticoagulant to address DVT in cancer-associated thromboembolism is low molecular weight heparin and factor Xa inhibitors, including rivaroxaban. However, in the following circumstances, the higher levels of anticoagulation should be considered; 1. recently diagnosed cancer; 2. extensive VTE circumstances, and 3. cancer treatment-related adverse effects, including vomiting."

Per Wan, T., et al;, (2021), "A standardised outpatient treatment pathway can significantly reduce the number of emergency department (ED) visits in patients with DVT, potentially improving patient care and reducing ED overcrowding. Most patients with DVT do not require hospital admission and outpatient treatment has similar outcomes as compared to treatment in hospital."                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient is not substantiated.