Diagnosis: Pulmonary Embolism
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented with left-sided chest pain radiating to her neck and back for 2 days, rated at a level of 9/10. Her past history is also remarkable for an elevated D-Dimer and she is on hormonal birth control. In the emergency department (ED), her vital signs were stable and an electrocardiogram (EKG) showed sinus tachycardia with a rate of 110, although her heart rate was 71 on presentation and 77 on admission. Computed tomography (CT) imaging of her chest was obtained that showed a subsegmental pulmonary embolism in the right lower lobe, posterior basal pulmonary artery. The chest x-ray was negative for an effusion or pneumothorax. She was given an intravenous (IV) fluid bolus and acetaminophen and was admitted for further treatment of her pulmonary embolism. She was started on Apixaban 10 milligrams (mg) twice a day and had her vital signs monitored every 4 hours with continuous pulse oximetry and cardiac monitoring.
She had a doppler ultrasound of her upper and lower extremities to rule out a deep vein thrombosis, and the results were negative. A thrombophilia work-up was started, she was seen by adolescent medicine, was given a Depo-Provera injection and stopped the oral contraceptive pills. She was discharged home with close outpatient follow-up.
The acute inpatient level of care is under review for medical necessity.
The requested health service/treatment of inpatient stay was not medically necessary for this patient.
This patient was admitted for treatment of a newly diagnosed pulmonary embolism. There are published criteria that are used to identify those patients who are considered low-risk with a pulmonary embolus and are safe for outpatient treatment. The criteria that are analyzed include if the patient is hemodynamically stable (concerns for systolic blood pressure less than 100, heart rate over 100, needing intensive care unit (ICU) care, or by clinician judgment); if thrombolysis or embolectomy is needed, if the patient has active bleeding or is at high risk for bleeding, if more than 24 hours of supplemental oxygen is necessary to maintain saturations 90% or higher, pulmonary embolus occurring while on anticoagulation, severe pain needing intravenous pain medication for more than 24 hours, medical or social reason for admission greater than 24 hours, creatinine clearance less than 30 milliliters per minute (mL/min), severe liver impairment, pregnancy, or documented history of heparin-induced thrombocytopenia (HIT). None of these are clearly present in this case. Based on the Hestia criteria, the patient could have been safely treated as an outpatient and even the short stay that occurred was not clearly necessary.
Therefore, based on the clinical information provided for review, the inpatient stay is not medically necessary at this time.