Diagnosis: Deep venous thrombosis.
Treatment: Inpatient admission.

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

This case involves then a male patient who presented to the Emergency Department (ED) with complaints of swelling to the lower extremity. The patient's past medical history was significant for cardiovascular accident (CVA). The patient reported that he noticed swelling that morning prior to ED arrival. The patient reported that he had recently discontinued taking Xarelto, approximately several months ago. The patient's examination revealed left lower thigh swelling with no tenderness to palpation, warmth or redness. The recommendation was made for laboratory diagnostic studies. The patient's duplex to the left lower extremity revealed an acute thrombus to the left common femoral vein. The patient was given Lovenox and was admitted for inpatient management of deep venous thrombosis (DVT). The patient's laboratory studies revealed an elevated white blood cell count of 15.45. The patient was also treated with medications, which included hydrocodone as well as me thocarbamol. The patient's electrocardiogram (EKG) revealed sinus arrhythmia with a possible lateral myocardial infarction. The patient continued with treatment and denied any further significant adverse events. The following day the patient was discharged given medical stability.

In review, this patient with past medical history of Lupus, cardiovascular accident (CVA), and history of deep venous thrombosis (DVT) had been noncompliant with his anti-coagulation medication for about several months. As a result, the patient presented with clinical signs and symptoms consistent with deep venous thrombosis. The patient reported acute left thigh pain on hospital presentation. However, based on the medical documentation, the patient did not exhibit any associated signs/symptoms of complicated DVT, such as leg edema, phlegmasia, mottling or motor/sensory changes to the affected (left) leg. In addition, the patient did not exhibit any associated symptoms of pulmonary embolism, such as dyspnea, shortness of breath, and/or elevated D-dimer.

Thus, as this was an uncomplicated deep venous thrombosis (DVT) due to medical noncompliance without other associated symptoms, it was prudent to re-start the anticoagulation, and discharge the patient from the Emergency Department. Literature review does not support that inpatient admission was medically necessary for this patient.

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

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