Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute deep venous thrombosis  

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male patient who presented to the Emergency Department for a chief complaint of left leg pain and swelling.  The patient had a past medical history significant for hypertension.  The patient reported that he pulled a muscle in his left leg several weeks earlier, and his symptoms were improving.  However, he noticed that the pain and swelling had returned.  The patient reported no history of traveling, no history of chest pain, no shortness of breath, no palpitations, no orthopnea, and no blood in the stool.  Examination findings included a temperature of 98, a heart rate of 66 beats per minute, a respiratory rate of 19 breaths/minute, and a blood pressure of 167/95.  The patient's physical appearance was abnormal, as he was lethargic and obese.  Musculoskeletal examination of the lower extremities were abnormal, including pedal edema and left lower extremity swelling.  Imaging was done, including a left lower extremity venous duplex with the impression of acute deep venous thrombosis of the distal left femoral, popliteal, lesser saphenous and posterior tibial veins.  The left common femoral vein and saphenous at neural junction were patent.  A chest x-ray was performed, and there were no acute cardiopulmonary processes noted.  The treatment plan was to admit the patient to the regular floor with intravenous (IV) fluids, Lovenox twice daily, echocardiogram in the morning, and deep vein thrombosis (DVT) prophylaxis.  While admitted to the hospital an oral medication was added to his Lisinopril in the form of Metoprolol 25 mg, and the patient's blood pressure demonstrated signs of improvement with the addition of Metoprolol.  Hematology was consulted and recommended that the anticoagulant medication be changed from Lovenox to Xarelto, a 3-month treatment plan.  The patient was safely discharged to home aftercare instructions were in place.

MCG state that inpatient admission for hypertension is indicated for systolic blood pressure (SBP) > 180 mm Hg or diastolic blood pressure (DBP) greater than 120 mm Hg, as well as evidence of acute or worsening target organ damage including hypertensive encephalopathy, altered mental status, cerebral infarction, intracranial hemorrhage, myocardial ischemia, heart failure and/or intravenous treatment is necessary. MCG state that inpatient admission for DVT is indicated for patients at high risk for acute complication including bleeding before anticoagulation, recent surgery, gastrointestinal [GI] bleeding, recent ischemic stroke, history of intracranial bleeding, history of active bleeding when anti-coagulated, active substance abuse or other risk factor thought to place the patient at high risk such that the ability to rapidly reverse anticoagulation is necessary.  The alternative to admission includes outpatient care in the emergency department, rapid treatment site, urgent care clinic, medical office or observation care.  
In the clinical records submitted for review, there were documentation of a diagnosis of hypertension and acute deep venous thrombosis of the distal left femoral, popliteal, lesser saphenous and posterior tibial veins.  However, hypertension was not at a level that could not have been treated at a lower level of care.  The acute DVT of the left lower extremity did not meet the indications for admission to the hospital and could have been treated at a lower level of care, such as observation.  Therefore, the denial of coverage for the inpatient hospital admission is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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