Diagnosis: Left axillary vein deep vein thrombosis.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is overturned.

This patient is an adult who presented to the Emergency Department (ED) for chest pain and left arm pain. A left upper extremity (LUE) ultrasound was performed that revealed an acute left axillary vein deep vein thrombosis (DVT) with physical findings and diminished pulses at the wrists. Vascular surgery was consulted and recommended anticoagulation along with computed tomography imaging. The patient was admitted to vascular for further management of an acute left axillary vein DVT. The patient received intravenous (IV) Heparin.

The patient underwent a left upper extremity (LUE) venogram and venoplasty for a high-grade stenosis. Post-operative management included pain control, IV anticoagulation, and IV fluids. Hematology was also consulted.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Most upper extremity DVTs are of little clinical consequence; however, in this case, there were physical findings that threatened circulation in the left arm and surgical intervention was appropriate.

The hospital admission is considered medically necessary. The patient presented to the Emergency Department (ED) for chest pain and left arm pain. She was diagnosed with left axillary vein DVT with physical findings and diminished pulses at the wrists. Initial anti-coagulation with heparin was appropriate as the most flexible anticoagulation method allowing surgery as soon as possible. However, it required time for effectiveness and would somewhat delay surgery. Therefore, the hospital admission is considered medically necessary.

"The treatment of upper extremity DVTs depends on the clinical presentation. The majority of patients present with limb swelling in the setting of central venous catheterization. The American College of Chest Physicians recommends that the clinician first determine the necessity of the line. If required (e.g., total peripheral nutrition), it should remain in place, and the patient should be started on anticoagulation therapy. If the line is not needed, it should be removed but only after the completion of 3 to 5 days of anticoagulation therapy. In the hospital, patients can be bridged to warfarin with unfractionated heparin. Patients should continue on warfarin for 3 to 6 months after diagnosis. The role of novel oral anticoagulant agents (e.g., dabigatran) is under current investigation. Still, recent data from the Swedish national anticoagulation registry (National Quality Registry for Atrial Fibrillation and Anticoagulation [AuriculA]) suggests that these drugs can be used to treat upper extremity DVT with acceptable efficacy and safety." (Grigorian & Nahmias, 2022)

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

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