Diagnosis: Deep Vein Thrombosis.
Treatment: Full Hospital Admission.
The insurer denied: Full Hospital Admission.
The denial is: Upheld.

The patient is a male with a history of metastatic renal cell cancer currently taking cabozantinib that presented to the hospital with a 3-day history of left lower extremity edema. The patient had a doppler that demonstrated a deep vein thrombosis. The patient was admitted for inpatient care including anticoagulation. The patient was subsequently evaluated by interventional radiology; clot retrieval was not recommended. The patient subsequently received physical therapy and was evaluated with a positron emission tomography (PET) / computed tomography (CT) due to concern of progression. The patient was discharged to home physical therapy/occupational therapy. The subject under review is the medical necessity for a full hospital admission.

The health plan's determination is upheld.

The full hospital admission was not medically necessary for this patient.
The authors of UpToDate note that hospitalization is not required for all patients with an acute deep vein thrombosis (DVT).
"Outpatient therapy can be considered when patients have all of the following features:
- Hemodynamically stable
- A low risk of bleeding
- No renal insufficiency
- A practical system in place at home for the administration and surveillance of anticoagulant therapy (e.g., good living conditions, caregiver support, phone access, understanding and ability to return to the hospital should deterioration occur)."
This patient meets these criteria. He was hemodynamically stable. He was evaluated for central nervous system (CNS) disease and had no clear evidence of an increased risk of bleeding. His renal status was stable. There is no evidence he lacked support at home for outpatient care (and he was ultimately discharged there). This approach is supported in the peer-reviewed literature and in national guidelines. For these reasons, medical necessity for inpatient care cannot be established.