Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of anxiety, depression, and fibroids status/post (s/p) myomectomy, who presented to the emergency room (ER) with a chief complaint of sharp right-sided mid back pain worse with movement and deep breathing. On presentation, she was afebrile with blood pressure (BP) 128/87, heart rate (HR) 107, respiratory rate (RR) 20, and oxygen saturation 95% on room air (RA). Her exam otherwise noted decreased breath sounds on the right side. Lab results showed white blood cell count (WBC) 11.3, Hemoglobin (HGB) 14, platelets (Plt) 258, sodium (NA) 138, potassium (K) 3.8, blood urea nitrogen (BUN) 7, creatinine 0.69, liver function tests (LFTs)  unremarkable, brain (or B-type) natriuretic peptide (BNP) normal, troponin undetectable, and elevated d-dimer of 1084. A urinalysis (UA) was not suggestive of an infection. An electrocardiogram (EKG) showed ST depression in the inferior leads. A computed tomography (CT) angiogram was performed showing large filling defect extending from the lobar pulmonary artery to the right lower lobe involving multiple segmental branches consistent with pulmonary embolism with pulmonary artery sarcoma not fully excluded and with an area of right lower lobe (RLL) opacification consistent with pulmonary infarction. The patient subsequently desaturated to 91% on room air (RA) and was placed on a nasal cannula. She was subsequently brought into the hospital with assessment that she had pulmonary embolism without right heart strain but with associated ST depressions in inferior leads with plans for heparin drip (gtt), telemetry, transthoracic echocardiogram (TTE), and pain control.
The next day, the patient was hemodynamically stable without hypotension, tachycardia, or hypoxia, and with stable HGB and pain controlled. She was subsequently discharged on Eliquis.
The health plan's determination is upheld.
This is a patient without a history of thromboembolism or bleeding who presented with a large pulmonary embolism. This was not associated with hemodynamic instability, hypoxia, evidence of right heart strain (no suggestion of such per notes, and troponin and BNP were both normal). Given this, the primary treatment was anticoagulation and monitoring without need for thrombolysis or thrombectomy. She remained hemodynamically stable throughout her stay without documented arrhythmias or hypoxia with oxygen saturation less than (<) 90% requiring supplemental oxygen support and was able to be discharged the next day on Eliquis. Given the extent of her pulmonary embolism, she was appropriate for observation for pain control, watching for arrythmias, assessing for hemodynamic instability, and further work-up with TTE. However, despite the size of her pulmonary embolism, in the setting of young age, hemodynamic stability on presentation, no heart strain, no prior bleeding history, no other high risk condition associated with thromboembolism while on anticoagulation, and no need for thrombolysis or thrombectomy, she would have been expected to be able to be discharged quickly on anti-coagulation. This patient was safe to treat at a lower level of care.