Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 

According to the documentation submitted, this is an adult with a history of cholecystectomy, tonsillectomy, and hypothyroidism. The patient presented to the emergency room (ER) from urgent care with complaints of deep vein thrombosis (DVT). Imaging of the lungs revealed bilateral pulmonary emboli (PE). The patient was admitted for care. During the admission, the patient was treated with Lovenox. The patient was transitioned to Xarelto. 

The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient presented to the hospital with a PE (pulmonary emboli) and DVT (deep vein thrombosis). There were no severe problems warranting a full hospital admission. The requested admission is denied based on Milliman Care Guidelines for Pulmonary Embolism (ORG: W0134) and Deep Vein Thrombosis of Lower Extremities (ORG: W0135). 

The patient presented to the emergency room (ER) with deep vein thrombosis (DVT) in the left lower extremity (LLE).  The patient had been complaining of left calf pain for several days and had gone to urgent care where a DVT (deep vein thrombosis) study was ordered.  The DVT study was positive, and the patient was instructed to go to the ER for further evaluation.  The patient denied chest pain (CP) and shortness of breath (SOB).  Vital signs included a temperature of 97.1 (degree) Fahrenheit, pulse 80, respirations 18, oxygen saturation 100% (percent) on room air.  The patient was in no acute distress.  Lungs were clear on exam and the patient was alert and oriented x 4 (person, place, time and event).  The patient had a non-focal neuro exam.  White blood cell (WBC) count was 7.8, hemoglobin was 15, and electrolytes were within normal limits.  The patient's electrocardiogram (EKG) showed no acute changes.  A computed tomography angiogram (CTA) of the chest was done to rule out pulmonary embolism (PE).  The study revealed bilateral segmental pulmonary emboli.  

The patient was admitted with a diagnosis of PE (pulmonary embolism).  The patient was initially treated with Lovenox and then switched to oral (PO) non-vitamin K antagonist oral anticoagulants (NOACs).  The patient had no evidence of hypotension or right heart strain.  The patient was afebrile and hemodynamically stable.  The patient was not hypoxic with good oxygen saturation on room air.  

The patient did not need acute inpatient hospitalization.  The patient could have been placed in observation status while diagnostic testing and treatment were initiated for up to 48 hours.  The patient had bilateral pulmonary emboli but was clinically and hemodynamically stable.  This patient could have been switched to oral anticoagulation and then discharged home on oral medications after a period of observation.

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 the full hospital admission is not substantiated.