Diagnosis: Acute portal vein thrombosis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is a female with a history of gastric bypass, migraines, and an ovarian cyst who was admitted to the hospital for right abdominal pain. On exam, she "appears comfortable" and tender in the right lower quadrant (RLQ). Computed tomography (CT) was negative. The magnetic resonance imaging (MRI) was done to rule out the distal right (R) portal vein, which was occluded on MRI. Heparin was started for portal vein thrombosis. She received an intravenous heparin drip, oral medications, a hematology consultation, and laboratory work.

An acute new portal vein thrombosis requires assessment and treatment as inpatient.

Acute portal vein thrombosis requires a prompt diagnosis and initiation of anticoagulation, certainly when symptomatic. Meta analyses suggest that anticoagulation therapy significantly increases the rate of portal vein recanalization and complete portal vein recanalization, and reduces the rate of thrombus progression, while the risk of bleeding did not significantly differ between patients who received anticoagulation therapy and those who did not.

"Direct oral anticoagulants (DOACs), including direct thrombin inhibitor (dabigatran) and factor Xa inhibitors (rivaroxaban, apixaban, edoxaban), are attractive oral alternatives to vitamin K administration (VKA) in many clinical settings. However, their role in cirrhotic patients is still unknown, since patients with remarkable liver disease have been excluded from most of the randomized clinical trials on DOACs. Indeed, in this setting potential hepatotoxicity and unpredictable pharmacokinetics related to various degree of hepatic elimination (apixaban 75% [percent], rivaroxaban 65%, edoxaban 50%, dabigatran 20%), cytochrome... plasma protein binding levels alterations, overcame the advantages of no need of laboratory monitoring, rapid onset of action and oral formulation." (Faccia, M., et al 2019).

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical necessity is substantiated.