Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Vein Thrombosis 
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld. 

This is a female patient with a medical history of pulmonary embolism and deep venous thrombosis (DVT) on Xarelto for life. The patient also had past medical diagnoses of iron deficiency anemia due to chronic blood loss, primary hypercoagulable state, recurrent acute DVT of the left lower extremity and sickle cell trait. The patient was sent from radiology for positive left lower extremity DVT. The patient's primary medical doctor ordered the ultrasound because she had complaints of increased swelling and constant non-radiating pain to her left lower extremity for several weeks.  This was typical of her DVT pain. The patient denied shortness of breath or chest pain. The patient had not been compliant with her medication for the past 2 weeks.  The patient's physical examination revealed tenderness and edema in the left lower leg. The patient was admitted to the hospital with acute left-sided DVT in the setting of not taking her Xarelto; Lovenox was administered.  The patient was started back on Xarelto and was counseled on medication compliance. The patient was subsequently discharged in stable condition.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. This patient with a history of multiple deep venous thromboses (DVT) of the left leg and one episode of pulmonary embolism (PE) over the past 20 years presented to the Emergency Department (ED) with 2-week history of left leg pain and edema. The patient's venous duplex imaging of the lower extremity support this patient's clinical presentation of DVT of the left common femoral vein. This episode was triggered by noncompliance to heranticoagulation, Xarelto medication. The patient had May-Thurner syndrome and had a left iliac venous stent placed in the past. The patient had an inferior vena cava (IVC) filter placed in temporarily and then subsequently removed, and was maintained on anticoagulation over 20 years. The patient was on Coumadin and then was switched to Factor Xa inhibitor, Xarelto. However, the patient had not been taking her Xarelto medication for the past 2 weeks, which was when the patient's symptoms of DVT recurred. In the ED, the patient's vital signs were: blood pressure 129/74, pulse 88, respiratory rate 20 and oxygen saturation of 100% on room air. Given that this was an uncomplicated DVT without evidence of pulmonary embolism, hemodynamic instability, active malignancy, hypoxia, chest pain, myocardial infarction, or heart failure, this was a case that could have simply been treated with restarting her anticoagulation medication in the Emergency Department and refilling her prescription for her anticoagulation. The patient could have been discharged home with close follow-up with her primary care provider (PCP).

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for inpatient admission is not substantiated. The insurer's denial should be upheld.