Diagnosis: Pulmonary embolism and deep venous thrombosis

Treatment: Inpatient admission, medication, monitoring

The insurer denied the inpatient admission. The denial was upheld.

The patient is a female who presented to the emergency department with a complaint of cramping pain and swelling in her right lower extremity for one day, and dull, sub-sternal chest pain and dyspnea that began acutely overnight. She has a past medical history of a pulmonary embolism (PE) in 2012, pulmonary nodule, diabetes mellitus type 2, and diabetic neuropathy. The patient was no longer on anticoagulation. The physical examination revealed tenderness (crampy feeling when palpated right calf, lateral, right thigh, right neck, shoulder, and upper arm). A CT angiography of the chest and duplex ultrasound of the bilateral lower extremities were completed, and the patient was noted to have a deep venous thrombosis (DVT) and mainstem pulmonary embolism. She was hemodynamically stable. The patient was started on heparin and admitted to the hospital. She was seen by Hematology, and they started the patient on Xarelto and sent a hypercoagulation work-up. The patient was stabilized and discharged.

MCG indicates that admission for a pulmonary embolism (PE) and/or deep venous thrombosis would be appropriate for a patient with a personal or family history of significant bleeding tendency or bleeding disorder that required monitoring beyond observation care, such as when continued monitoring of their response to anticoagulation is needed. The records failed to support the patient had a necessity for continued monitoring of her response to anticoagulation beyond observation care. The patient was hemodynamically stable. The patient had a strong family history of deep venous thrombosis/pulmonary embolism, however, the records failed to support the patient could not be monitored at a lower level of care, such as observation status.

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