Diagnosis: Right Leg Pain and Swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient in this case is a male. He has a history of recurrent DVT (deep venous thrombosis) and was on treatment with anticoagulation. He presented to the emergency department with a two day history of pain in the right leg along with pleuritic chest pain for one day. He had been off anticoagulation for several days because he was out of state and unable to get a new supply of Eliquis.

The patient's CT (computed tomography) chest revealed no pulmonary embolism and ultrasound revealed an acute partially occlusive left leg deep vein thrombosis. No acute DVT (deep venous thrombosis) was seen in the right leg. He was admitted to the hospital and treated with IV (intravenous) heparin infusion. On the following day, he had no pain or swelling in either leg. Thrombophilia labs were recommended by hematology, and also recommended was resumption of Eliquis. The labs could not be obtained despite two attempts. He was discharged the next day.

No, the Inpatient admission was not medically necessary.
This patient had an acute partially occlusive DVT (deep venous thrombosis) in the left leg not associated with symptoms. He had come to the ED (emergency department) with right leg symptoms, which notably had resolved by the time he was admitted. He had been off Eliquis. He was hemodynamically stable, and there was no evidence of circulatory compromise in the left leg. Pulmonary embolism had been ruled out. He did not require acute care inpatient hospitalization.