Diagnosis: Leg swelling.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a female with a past medical history significant for coronary artery disease, hypertension, migraine headaches, provoked venous thromboembolism following knee surgery, and chronic right knee pain who presented with complaints of right leg swelling and knee pain of 5 days duration. She also complained of shortness of breath, which started 3 days before the presentation. The patient denied any trauma to the leg, fever, warmth, or erythema of the leg. The patient's symptoms such as leg pain and shortness of breath were aggravated by climbing stairs. At the same time, the patient denied chest pain, cough, hemoptysis, palpitations, lightheadedness, dizziness, or syncope.

The inpatient hospital admission was not medically necessary for this patient.

According to nationally accepted standards of care, admission at the acute inpatient level of care is required in cases when pulmonary embolism is associated with hypoxemia, vital sign abnormality, history of chronic cardiopulmonary disease such as congestive heart failure (CHF), coronary artery disease, chronic obstructive pulmonary disease (COPD), or cor pulmonale, cardiac arrhythmias of immediate concern, right ventricular dysfunction or strain, positive cardiac biomarkers, need for administration of intravenous opioids, or in patients with a high risk of acute complications such as bleeding before anticoagulation, recent surgery, recent ischemic stroke, history of active bleeding while anticoagulated, also in cases when there is a contraindication to outpatient use of medications with rapid anticoagulation effect and some other circumstances not relevant to this clinical case.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.