Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Complex Regional Pain Syndrome

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This case involves a teenager who was admitted to the hospital.  The physical exam showed swelling and tenderness, the patient's left hand was swollen compared to the right, the left arm was tender to palpation, worse in the inferior to mid-upper arm, the patient's left upper extremity was cold to touch, and sensory deficit and weakness were present. The patient also was unable to move their fingers, flex/extend at the wrist or elbow, or lift arm above head due to pain; poor sensation was reported below the mid-upper arm. 

Based on the evaluation, the physician felt that admission was required due to certain components of the patient's treatment plan that could only be accomplished in an inpatient setting, as the patient required frequent neuro checks and vital signs.
 
During physical therapy the next day, the patient stated that "my arm is all better." The patient tolerated the treatment well, progressing with ambulation distance without pain or motor deficits. 

In this case, this patient with a history of recurrent urticaria and rhinitis presented to the pediatric emergency department (ED) with a sudden onset of numbness and tingling of the left arm that started 2.5 hours prior. After volleyball practice, the patient suddenly felt pain and numbness of the left upper extremity with color change to hand. The patient was also unable to move their fingers or flex/extend their wrist and elbow, and had a minor headache, cough and congestion. The patient took ibuprofen with no relief. Vital signs in the ED were as follows: blood pressure 108/67, pulse 90, respiratory rate 19, temperature 36.8, oxygen saturation (SpO2) 98%. The white blood cell (WBC) count was 12.1, c-reactive protein (CRP) was 6.4. A stroke code was called, and neurology was consulted.

Computed tomography (CT) of the head showed no intracranial hemorrhage or concern for stroke, computed tomography angiogram (CTA) showed no evidence of large vessel occlusion, Doppler study was negative for deep vein thrombosis (DVT), magnetic resonance imaging (MRI) showed no evidence of infarct, hemorrhage, or mass defect, X-rays of the left upper extremity (LUE) showed no fracture. The LUE was cooler than right upper extremity (RUE) from mid upper arm to hand, tenderness to palpation, no swelling appreciated in the bilateral arms, erythema of left forearm with normal sensation and motor exam limited by pain. 

Based on the evaluation, the physician felt that admission is required due the components of the patient's treatment plan can only be accomplished in an inpatient setting, the patient required frequent neurology checks and vital sign checks. Neurology was consulted and the patient completed routine and continuous electroencephalogram (EEG) without abnormal findings. 

On day 2 of admission, the patient's weakness, pain, and decreased sensation resolved. 
It was noted in the discharge summary that the diagnosis remained slightly unclear, though it was felt to most likely be complex regional pain syndrome. The patient was medically cleared for discharge to home on day 2.

Although the physician stated that the patient required admission for required frequent neurology checks and vital signs, laboratory and diagnostic findings showed no evidence or concern of stroke. The services planned and rendered could have been given in a lower level of care such as outpatient care in the emergency department, observation care, rapid treatment site, urgent care center, or medical office. As such, the inpatient admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.