Diagnosis: Pulmonary Embolism.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission. The denial is upheld.

The patient has a history of testicular cancer and prior deep vein thrombosis (DVT). The patient had not been on anticoagulants at the time. The patient was diagnosed with COVID (coronavirus). The patient presented to the emergency department (ED) with complaints of left lower calf pain. The patient was tachycardic, denied fever, chest pain (CP) and shortness of breath (SOB). Vital signs: Temperature 99.3, Blood Pressure 128/59, Heart Rate 115, Respiratory Rate 22, and Oxygen (O2) saturations 100% (percent). The patient was alert and oriented x3 (person, place, and time), in no acute distress (NAD), Lungs were clear, and cardiovascular systems (CVS) were normal. The patient was tachycardic, with cyanosis, clubbing or edema. The patient had some left calf pain on palpation. White blood cell count (WBC) was 9.8, hemoglobin (Hb) 14.9, electrolytes were within normal limits (WNL). COVID Test was positive. Creatine phosphokinase (CPK) was normal and Troponin was normal. Chest x-rays revealed (CXR) no acute pathology.

Computerized tomography angiography (CTA) revealed bilateral (B/L) pulmonary embolism (PE). There were also some bilateral ground glass opacities consistent with COVID. The patient was not hypoxic, was admitted for the treatment of pulmonary embolism (PE). The patient was started on Apixaban. Echocardiogram did not reveal any right heart dilatation or strain. Left ventricular function was normal. DVT was negative. The patient was treated with Heparin drip for PE as there was concern that he had failed oral (PO) anticoagulation (AC). A hematology consultation was obtained. They opined that this patient had not failed oral anticoagulation (PO AC). He had not been on AC, so it was not a failure and they recommended to start back on PO AC.

The patient remained stable after admission (other than some tachycardia). The patient was not hypoxic. Oxygen saturation was 97% on room air. This patient was switched to oral (PO) Apixaban as per Hematology recommendations and was discharged home.

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation periods could be for up to 48 hours. The patient was stable after admission and could have been discharged home on PO Apixaban for his PE after a period under observation. The patient was stable for follow up (FU) in outpatient setting after that.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial is upheld. Medical Necessity is not substantiated.