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202004-128019

2020

Fidelis Care New York

Medicaid

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis: Lower leg blood clot.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

Yes, the Inpatient admission was medically necessary.

The patient in this case is a man with a history of left lower extremity DVT (deep venous thrombosis) treated in the past with a course of warfarin. He was not taking warfarin at the time of the admission in question. He was brought to the ED on after a fall with head trauma and no loss of consciousness. His daughter noted that one week before this visit, he was involved in an accident as a pedestrian struck by a vehicle and that he had sustained a "microscopic brain bleed" and also had sustained L1-L4 vertebral body fractures. He was in the hospital for six days and discharged with a one-week course of Keppra. His daughter witnessed him falling out of bed.

At the time of initial evaluation, the patient complained of headache and also complained of left lower extremity pain and swelling. Doppler ultrasound of the left leg revealed deep venous thrombosis of the left popliteal vein and also thrombosis of the left greater saphenous vein extending up to the junction, likely chronic. He was diagnosed with acute DVT along with chronic DVT. Evaluation also revealed a 10cm laceration along the right buttock with surrounding erythema and ecchymosis. A right kidney hematoma was also identified, along with right 8th rib fracture, L1-L4 fractures, left hip contusion and mild anemia. Injuries were from his prior accident one week before this presentation.

The patient was admitted and treated with full dose anticoagulation and also monitoring. He had stable hemoglobin while in the hospital without any concerning symptoms. He was seen by physical therapy. He was discharged to sub-acute rehab. It was noted that he was admitted because he was unable to ambulate on his own and he had significant pain due to his multiple injuries requiring intravenous pain medications.

The patient in this case was diagnosed with acute deep venous thrombosis. He required full dose anticoagulation. Records also indicate that he had multiple injuries from his trauma one week before this admission. These included a hematoma on his kidney. He had inability to walk, and he also required intravenous pain medications. With initiation of full-dose anticoagulation he was at risk of bleeding due to his recent injuries. He required monitoring for that reason, and he also required treatment for pain and assessment due to his inability to walk (which was due to his multiple traumatic injuries). He also had a large wound on his buttock that required cleaning and appropriate care, which it had not been getting. Once it was clear that he was tolerating anticoagulation without bleeding and pain was under reasonable control, he was discharged.

It is standard in most cases to treat DVT with outpatient management. However, this patient was at increased risk for bleeding, and this largely justified acute care inpatient admission while full-dose anticoagulation was started.

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