Diagnosis: Splenic infarction.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is an adult with past medical history of congenital aortic disorder, dyslipidemia who presented to the emergency room (ER) with abdominal pain and nausea. Her vital signs and laboratory were unremarkable except for mild leukocytosis. A computed tomography (CT)/ultrasound (US) showed possible splenic infarct. She was placed on heparin drip. She was seen by vascular surgery and hematology. No interventions were recommended. She was discharged home on Eliquis.

The splenic infarct showed in imaging would be considered venous thromboembolism (VTE). In this case, the patient required anticoagulation therapy, heparin drip for a newly diagnosis of VTE. Therefore, the requested hospital admission was medically necessary.

Per Milliman Care Guidelines (MCG), "Initial inpatient care needed for anticoagulation therapy, as indicated by ALL of the following:

- Temporary subtherapeutic anticoagulation unacceptable because of high short-term risk of venous or arterial thromboembolism due to 1 or more of the following:
- Venous thromboembolism newly diagnosed or within past 12 months
- Underlying malignancy
- Patient with mechanical cardiac valve
- Underlying thrombophilia (hypercoagulable state, e.g., protein C or protein S deficiency, antithrombin deficiency, antiphospholipid antibodies)
- Patient at temporary high risk of thromboembolism (e.g., status post orthopedic surgery)
- Atrial fibrillation with rheumatic valvular heart disease (e.g., mitral stenosis)
- New-onset postoperative atrial fibrillation in patient with history of stroke, transient ischemic attack, or other thromboembolism ".

Chapman, J., Helm, T. A., & Kahwaji, C. I. (2022), "Splenic infarction occurs when the blood supply to the spleen is compromised resulting in tissue ischemia and eventual necrosis. It may be the result of arterial or venous occlusion. The infarction may be global or involve a small segmental area of the spleen depending on which vessel is occluded. Typical presentation includes left sided abdominal pain in a person with an underlying hematologic disorder, hypercoagulable state, blood-borne malignancy, blunt abdominal trauma, or embolic illness."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the full hospital admission is substantiated.