Appeal type: Medical necessity
Decision: Upheld

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

This is the case of a male with a past medical history of hypertension, heart failure, prostate cancer, pulmonary embolism on Xarelto, and left leg deep vein thrombosis (DVT). The patient presented to the Emergency Department (ED) with left foot pain/swelling for the past two days. The patient denied fever, headache, chest pain, shortness of breath, nausea, vomiting, or diarrhea. The blood pressure was 180/87. The physical examination revealed the patient was sitting on the chair in mild distress. There was swelling in the left foot. The duplex study of the lower extremities revealed an acute appearing partially occlusive venous thrombosis of the left popliteal and posterior tibial veins of similar extent. The patient was started on a heparin drip and was admitted. The computed tomography (CT) scan of the chest revealed no pulmonary embolism. During the hospitalization, the patient was switched to oral Xarelto. The patient was later in stable condition.

Workup for DVT revealed an acute left popliteal and posterior tibial vein of the left leg that was partially occlusive. All bloodwork was within normal limits. There was no history of intolerance to anticoagulation, bleeding with anti-coagulation or other contraindications to anticoagulation therapy such as recurrent DVT or persistent DVT while on anticoagulation.

The patient was not on anti-coagulation, and was asymptomatic, so simple outpatient therapy with anticoagulation with a direct thrombin inhibitor would suffice. Given the patient's history of DVT and pulmonary embolism (PE) in the past, a CT(computed tomography) angiogram of the chest with PE protocol would have ruled out any pulmonary embolism. This test did not require inpatient stay. Heparin drip was also not indicated. The correct sequence of events should have been ED presentation, vascular or pulmonary consultation, venous duplex and CT for PE protocol, prescription for Xarelto with first dose in ED, and discharge with follow up with Pulmonology and Vascular Surgery as outpatient. Workup for hypercoagulable state or considerations for inferior vena cava (IVC) filter all can, and should be done, as an outpatient.

Some exclusion criteria for outpatient management of acute DVT are the following: This patient had none of these.

1) Suspected or proven concomitant PE.  2) Significant cardiovascular or pulmonary comorbidity. 3) Iliofemoral DVT. 4) Contraindications to anticoagulation. 5) Familial or inherited disorder of coagulation: antithrombin III (ATIII) deficiency, prothrombin 20210A (Factor II Mutation). 6) Familial bleeding disorder. 7) Pregnancy. 8) Morbid obesity (>150 kilogram).  9) Renal failure (creatinine >2 milligramg/deciliter). 10) Unavailable or unable to arrange close follow-up care. 11) Unable to follow instructions. 
12) Homeless. 13) No contact telephone. 14) Geographic (too far from hospital).

There was no medical necessity for inpatient admission on this patient. The denial of coverage should be upheld. There were no special reasons for admission, heparin drip, or inpatient stay to convert anticoagulation from heparin to Xarelto.

The patient could have had all workup including ultrasounds and CT scans in the ED, given Xarelto, and discharged with follow up with Hematology and Pulmonology. He did not have shortness of breath, decreased oxygen saturation, chest pain or other symptoms.  

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.       

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.