Diagnosis: Pulmonary Embolisms

Treatment: Inpatient Admission

The insurer denied the inpatient admission.

The denial was upheld.

The is a morbidly obese female patient who presented to the Emergency Department (ED) with complaints of right leg and foot pain and difficulty ambulating after falling from steps a few months prior to presentation; swelling and erythema were noted around her ankle. The patient was alert and oriented x 3 and was able to speak in full sentences. She denied fever, cough, shortness of breath or chest pain. Vital signs at presentation were; temperature of 98.3°F, a blood pressure of 177/100, a heart rate of 105, a respiratory rate of 20 and an oxygen saturation of 94% on room air; her lungs were clear. Cardiovascular system (CVS) heart sounds S1 S2 were normal. Laboratory work up was performed that revealed white blood cell (WBC) count 12.5K with 65% Polys, hemoglobin was 14 and electrolytes were within normal limits with elevated D-Dimers. A computed tomography angiogram (CTA) of the chest was performed that revealed bilateral pulmonary embolism (PE). No right ventricular strain was noted. The patient was admitted to the hospital for treatment for pulmonary embolisms. A deep vein thrombosis (DVT) study was done with negative results. A chest x-ray was performed that showed no acute pathology. An x-ray of the right foot was done that revealed a fracture of the distal fibula. Intravenous (IV) fluids, IV antibiotics, pain medications, and subcutaneous Lovenox were administered. The patient was discharged home after treatment after a period of medical stability.

This patient did not need acute hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. She was afebrile and hemodynamically stable throughout. The patient was seen by Hematology who recommended switching to oral anticoagulants at discharge and a follow-up in the outpatient setting. The patient was seen by Orthopedics who did not recommend any acute intervention. The patient was WBAT (weight bearing as tolerated). A stirrup brace or CAM boot was recommended at discharge with a follow-up in the outpatient setting. The patient could have been treated with oral antibiotics if needed. The patient was seen by Hematology and Orthopedics and cleared for discharge on oral medications.

The patient was stable to be discharged on oral medications after a period in observation. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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