Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Upper Extremity deep vein thrombosis (DVT). 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Admission. 
The denial is upheld. 

This patient is a female with a history of deep vein thrombosis (DVT) who presented to the emergency department (ED) with right arm pain. The pain started three days before this presentation, initially in the upper back, with radiation to the right arm and right chest. The patient denied shortness of breath or palpitations and had no fevers. The prior history of DVT was caused by pregnancy, and treated with Lovenox. The hypercoagulable work-up at that time was negative. 

Vital signs in the ED were stable, including a blood pressure of 116/78 and a heart rate of 70. On exam, the patient was awake and well oriented with no distress. A cardiac exam showed no murmur; breath sounds were equal and clear to auscultation bilaterally with nonlabored respirations. 

The laboratory studies revealed normal electrolytes and renal function. The hemoglobin was 12, and the white blood cell count was 5.8. The liver function tests were fairly unremarkable. A D-dimer was obtained in the ED and was borderline elevated at 0.58. The ED obtained the upper extremity duplex study, which showed an occlusive thrombus in the proximal right brachial vein. The chest x-ray showed mild bilateral patchy infiltrates. 
The patient was admitted to the hospital due to upper extremity DVT. A computed tomography angiography (CTA) of the chest was performed and showed no pulmonary embolism (PE). The medical team also ordered another hypercoagulable workup and consulted hematology. The hematologist assessed the patient later in the day and noted normal antithrombin three (III) and protein C antibodies. They requested antiphospholipid antibodies, lupus anticoagulant, and beta-2 glycoprotein. In addition, they requested factor 5 (V) Leiden and prothrombin mutation. Their final recommendation was to place the patient on a direct oral anticoagulant. 
By the following day, the patient remained hemodynamically stable. The medical team opted to continue Lovenox on discharge while awaiting antiphospholipid antibodies. 

At issue is the medical necessity of the Inpatient Admission. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient. 

Based on the provided documentation, there is no indication for the inpatient admission for this hemodynamically stable patient with upper extremity DVT. Multiple societies have established treatment protocols for acute DVT, and admission is not indicated unless the patient is suffering from secondary complications of the DVT. This patient was hemodynamically stable and had no evidence of pulmonary embolism, heart strain, hypoxemia, severe tachypnea, severe pain, or threatened limb to warrant an inpatient hospitalization. Initiation of anticoagulation, either with enoxaparin or a direct oral anticoagulant, can be followed in the outpatient setting with the same outcomes. There were no clinical indications for admission to the inpatient level of care, as this was an uncomplicated venous thrombosis, with low risk for complications. 

Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary.