Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  DVT.
Treatment:  Inpatient hospital stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a male with a past medical history significant for hypertension who was enrolled in the Suboxone program.  He presented to the emergency department from an urgent care center with suspicion for deep vein thrombosis (DVT).  He went to the urgent care center because of lower extremity swelling that started approximately 4 months before the presentation.  The swelling was associated with calf pain.  The patient denied any shortness of breath, dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea.  The patient denied fever, chills, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, or palpitations.

At the time of the initial evaluation, the patient was afebrile, pulse rate was 82 beats per minute (bpm), respiratory rate 16, blood pressure 128/69, and oxygen saturation 98% on room air.  The patient was in no acute distress.  He had a regular rate and rhythm.  Lungs were clear to auscultation bilaterally.  The abdominal exam was within normal limits.  The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that white blood cell count was 10.0, hemoglobin 15.9, hematocrit 45.9, platelets 171.  Sodium was 136, potassium 4.8, chloride 100, bicarbonate 29, blood urea nitrogen (BUN) 15.2, creatinine 1.0, and glucose 104.  The duplex ultrasound demonstrated DVT occlusive in the distal left femoral and distal left popliteal veins and non-occlusive DVT in the medial left femoral and proximal popliteal veins.

The patient was admitted to the hospital and received treatment with a Heparin drip.  In the hospital, the patient was seen by vascular surgery, and according to their recommendations, was switched to Eliquis.  Since the patient remained in stable clinical condition, he was discharged home on the next day after the day of admission.

The inpatient hospital stay was not medically necessary for this patient.  Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.  The patient could have been started on Eliquis while in the emergency department and discharged home with a recommendation to follow up with a primary care physician.  Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.

The patient was admitted to the hospital because of acute DVT.

The treatment of acute deep vein thrombosis includes:  1)  Anticoagulation, 2)  Sometimes inferior vena cava filter, thrombolytic drugs, or surgery.

In most patients, anticoagulation should be started immediately, as a delay in therapy may increase the risk of potentially life-threatening embolization.  Treatment is aimed primarily at pulmonary embolism (PE) prevention and secondarily at symptom relief and prevention of DVT recurrence, chronic venous insufficiency, and postphlebitic syndrome.  Outpatient therapy can be considered when patients have all of the following features:  1)	 Hemodynamically stable, 2)  A low risk of bleeding, 3)  No renal insufficiency, and 4)  A practical system in place at home for the administration and surveillance of anticoagulant therapy.

Outpatient therapy is not appropriate in patients with:  1)  Massive DVT (eg, iliofemoral DVT, phlegmasia cerulea dolens), 2)  Concurrent symptomatic pulmonary embolism (PE),  3)  High risk of bleeding on anticoagulant therapy, or 4)  Comorbid conditions or other factors that warrant in-hospital care.

The review of the medical records clearly demonstrated that the patient had no contraindications for the initiation of anticoagulation as an outpatient.