Diagnosis: Anemia, Pulmonary Embolus

Treatment: Inpatient Hospital Admission

The insurer denied the Inpatient Hospital Admission. The denial was reversed.

This is a middle age female patient who presented to the Emergency Department with difficulty breathing for two weeks. It was reported that the patient had been in the emergency room 2 weeks prior to this presentation with the same complaints. At that time the patient's hemoglobin level was 6.8. The patient was discharged home on iron pills. The physical examination revealed that the patient had no cough or shortness of breath however; the patient reported that shortness of breath was noted on exertion. The patient was admitted to the hospital with dyspnea secondary to anemia rule out pulmonary embolism. The patient had a chest x-ray, revealing no acute disease. A Doppler study of the lower extremities was performed which revealed a popliteal deep vein thrombosis. The Computer Tomogram scan of the patient's chest revealed bilateral pulmonary emboli. The patient was evaluated by gastroenterology where it was determined that the patient had iron deficiency and was given intravenous iron. Additionally, the patient hospital treatment included anticoagulant therapy for the treatment of the patient's deep vein thrombosis and pulmonary emboli, intravenous fluids, and 1 unit of packed red blood cells. The patient was stabilized and discharged. The patient was to be treated as an outpatient for anemia.

This patient was found to have pulmonary emboli in setting of significant anemia. Moreover, both the Tn levels were elevated and the echocardiogram showed evidence of right ventricular strain. These are generally associated with in hospital management. In fact, as noted by the most recent Cochrane review, the data supporting outpatient management of pulmonary embolus remains unclear.
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The carrier's denial of coverage for the inpatient hospital admission is reversed. The medical necessity is substantiated.