Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary embolism.
Treatment Inpatient Hospital Stay.
The insurer denied the inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history significant for Hodgkin's lymphoma, immune thrombocytopenic purpura (ITP), atrial fibrillation, and aortic valve stenosis who presented to the emergency department with complaints of worsening shortness of breath over the course of 2 months. On the day of admission, the patient went to see his primary care physician who ordered a D-dimer test, which was abnormal. Therefore, he underwent a computed tomography (CT) angiogram of the chest that confirmed the diagnosis of pulmonary embolism. The review of systems was positive for long-standing left lower extremity swelling and calf pain.
On the physical exam, the patient was afebrile. His heart rate was 60 beats per minute (bpm), respiratory rate 18, blood pressure 135/65, oxygen saturation 100% on room air.
The patient appeared to be a well-developed, well-nourished individual. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. He had one plus left lower extremity edema. 
The patient was admitted to the hospital with a diagnosis of acute pulmonary embolism. The admitting physician stated that there were no signs of right heart strain. The admitting physician also indicated that the patient had a history of ITP but the platelet count was stable. Considering the fact that the patient had new nodules in the left upper and left lower lobes, as well as a 1.3 x 12.7 centimeter (cm) left upper quadrant mass with bulky adenopathy, a lymphoma was suspected, and therefore hematology/oncology consultation was requested.
In the hospital, the patient underwent a lower extremity venous duplex study that revealed a popliteal and peroneal vein deep vein thrombosis.
For the treatment of deep vein thrombosis (DVT) and PE, the patient was started on Lovenox injections.
During the hospital stay the patient underwent a CT-guided liver biopsy that revealed the presence of spindle cell neoplasm, leiomyosarcoma. Since the patient's condition improved, he was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.
The inpatient stay was medically necessary, considering the complexity of the situation as well as the intensity of care provided during this admission.
The Pulmonary Embolism Severity Index (PESI) predicts the 30-day outcome of patients with pulmonary embolism using 11 clinical criteria. In this clinical case, the patient received 94 points, which signified an intermediate risk of 30-day mortality. Therefore, the patient could not be discharged from the emergency department and required admission to the hospital. The patient had other significant medical problems, particularly the presence of a mass that was suspicious for malignancy based on the imaging studies as well as the history of ITP.
Venous thromboembolism is often associated with malignancy. Therefore, obtaining a tissue biopsy was essential in order to decide about the further treatment of the possible malignancy.
At the same time, the patient had an increased risk of further thromboembolic complications, because the anticoagulation should have been interrupted to get the tissue biopsy done. Those circumstances significantly contributed to the complexity of the patient's care.
This coincides with the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 23rd Edition for Pulmonary Embolism. Based on the criteria, admission at the acute inpatient level of care is indicated for "Other condition, treatment, or monitoring requiring inpatient admission." In this clinical situation, the patient presented to the hospital with acute DVT and acute pulmonary embolism, which was associated with underlying malignancy. Therefore, the admission to the hospital to work up the malignancy was essential and justified admission at the acute inpatient level of care.