Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Vein Thrombosis (DVT)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a female with past medical history of ST (interval on EKG [electrocardiogram])-elevation myocardial infarction (STEMI), duodenal ulcer, acute coronary syndrome (ACS), and obesity. She presented to the hospital with complaints of lower extremity swelling for a few weeks, and some shortness of breath (SOB). The patient was tachycardic in the Primary Medical Doctor's (PMD's) office. She reported an international flight a few weeks prior. At presentation to the Emergency Department (ED), vital signs were temperature (T) of 100, heart rate (HR) 116, blood pressure (BP) 136/97 and oxygen (O2) saturation (sats) 96% (percent) on room air. The patient's lungs were clear. Tachycardia and some swelling of lower extremity was noted. Labs revealed hemoglobin 7.7 with hematocrit 28.2. Brain natriuretic peptide (BNP) and troponin were normal. EKG showed sinus tachycardia with no acute ST-T (interval on EKG) changes. Computed tomography angiography (CTA) revealed bilateral small to moderate pulmonary embolism and deep vein thrombosis (DVT) study was also positive for DVT. The patient was admitted for treatment. An echocardiogram was done which revealed normal left ventricular (LV) function and normal right ventricular (RV) function. No right heart strain. The patient was treated with intravenous (IV) heparin initially. She remained stable after admission. Repeat vital signs in the evening were 98.6 T, BP 104/71, HR 98 and O2 sats 96% on room air. The patient was also evaluated for anemia and weight loss. She was given iron injection and received 1 unit of packed red blood cells (PRBC). Stool was negative for occult blood and no active bleeding was noted. Her hemoglobin remained stable, and the patient was switched to Apixaban. Myocardial infarction (MI) was ruled out. The patient was discharged with planned outpatient workup for her anemia and to rule out Colon Cancer.

This patient was afebrile and hemodynamically stable. Clot burden was not high. She was not hypoxic on room air. She was awake and alert and was tolerating an oral diet. There was no right heart strain on echocardiogram and MI was ruled out. The patient was discharged home on oral Apixaban with outpatient follow up.

This patient could have been placed in Observation status while diagnostic testing and treatment were initiated. This patient could have been discharged after a period under observation which could be for up to 48 hrs.

This patient remained stable after admission, and she was stable for discharge on oral Apixaban. There was no clear indication for transfusion. The patient was afebrile, hemodynamically stable, not hypoxic, no EKG changes and hemoglobin remained stable with no active bleeding, however if deemed necessary could have been done while the patient was in observation.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient. 

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