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 (ED) with left leg swelling. The patient reported spraining his ankle a few weeks before this event, with subsequent edema a week later. There were no other associated symptoms, including chest pain, shortness of breath, or dizziness. The patient reported a familial history of thrombophilia in his mother. He denied any long-distance travel or immobilizations. He took ibuprofen for pain and does smoke cigarettes. Assessment in the emergency department (ED) revealed a deep vein thrombosis (DVT) at the left popliteal vein. The ED initiated a therapeutic dose of Lovenox. His vital signs were stable, with a normal blood pressure and heart rate. A knee x-ray was performed, which was negative for fractures. Laboratory studies were obtained, which showed a white blood cell count of 3.7, hemoglobin of 21, hematocrit of 62, and platelets of 160. The renal function was normal, and the electrolytes were normal as well. The international normalized ratio (INR) was 1.17. The ED provider decided to admit the patient to the hospital due to the elevated hemoglobin. Hematology was consulted, who assessed the patient on the day of admission. They recommended ruling out polycythemia vera, ordering a phlebotomy, and checking for janus kinase (JAK) 2 abnormalities, testosterone level, and erythropoietin level. The patient denied taking any steroids or testosterone when questioned by the hematologist. The hematologist recommended chronic anticoagulation.
The next day, the patient felt well, was still reporting left lower extremity pain, and wanted to be discharged. His vital signs were stable. He was switched to Eliquis. The medical team noted the plan for a therapeutic phlebotomy per the orders from hematology. The attending physician subsequently documented later in the day that the patient would get phlebotomized tomorrow. The patient refused phlebotomy and refused blood work for a JAK2 mutation but agreed to it for the following morning. Hematology recommended follow-up with the hematology clinic after discharge.
The patient was again asking to be discharged, as he was scheduled for work. His vital signs remained stable. The patient left the hospital against medical advice.
The issue for review is whether the inpatient stay is medically.

The inpatient stay was medically necessary.  The patient had a unilateral popliteal DVT, which appeared to be provoked by a traumatic leg injury. On this basis, treatment for the DVT did not require hospital admission. However, the patient had a concurrent severe elevation of the hematocrit to 62, with a concurrent DVT, thus qualifying him for inpatient hospitalization.
The presence of polycythemia vera and a family history of thrombophilia increased the risk of catastrophic outcomes for this patient, hence the need for an inpatient hospitalization, with extensive evaluation and treatment of the underlying causes. The patient likely requires lifelong anticoagulation, and the inpatient hospitalization would help determine the treatment course. The medical literature supports the admission to inpatient care, based on a DVT with likely polycythemia vera and severely elevated hematocrit possibly causing hyperviscosity syndrome.