Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Other/Fluid in the left hip joint area.
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This case involves a woman with hypertension and rheumatoid arthritis who presented to the emergency department with severe left hip pain. Ten days before this presentation, she was seen in a rheumatology clinic, given a 20-day Prednisone taper, and was started on Methotrexate. The patient reported compliance with these medications; however, her left hip pain persisted. Her vital signs in the emergency department (ED) were fairly normal, with a temperature of 99.2 F (Fahrenheit), pulse rate of 82 beats per minute (bpm), and a blood pressure of 105/73 millimeters of mercury (mmHg). The patient appeared uncomfortable secondary to pain. She refused to flex or extend the left hip due to severe pain. She did not have any erythema or induration.
The ED provided the patient with pain medications, including Tylenol and Percocet. She subsequently developed a temperature of 100.2 F, which raised the suspicion of a septic joint. Therefore, orthopedic surgery was asked to evaluate, who recommended a magnetic resonance imaging (MRI) of the left hip. The MRI showed a joint effusion, so the patient was sent to interventional radiology for arthrocentesis. Only a small amount of fluid drained, which was clear and nonpurulent. Further analysis could not be performed.
The patient was admitted to the hospital for further monitoring. The orthopedic surgery team assessed the patient, performed a direct patient examination, and had low suspicion of a septic joint. Antibiotic treatment was not recommended. Laboratory studies were fairly stable, with a normal white blood cell count on the day of admission and the subsequent day. Her sedimentation rate was 59, and the C-reactive protein (CRP) was 3.9. The patient was tested for COVID (coronavirus disease) and was negative.
The patient remained in the hospital, was serially examined by orthopedic surgery, remained afebrile, and was treated with supportive measures. The labs remained stable. The patient received Oxycodone 5 mg (milligrams) every 4 hours as needed for pain. The patient's steroid dose was increased to improve comfort and decrease inflammation.
The patient's range of motion improved, and she was released home with primary care physician and rheumatology follow-up.
The question is whether an inpatient admission was medically necessary.

I uphold, in whole, the health plan's determination of medical necessity.

An inpatient hospitalization was not warranted in this case.
I carefully reviewed the provided documentation. The patient presented to the hospital with left hip pain with known rheumatoid arthritis and was started on outpatient treatment with Prednisone and Methotrexate. The patient was experiencing difficulty ambulating and underwent appropriate evaluation in the emergency department, with an MRI of the hip and aspiration of the hip fluid by interventional radiology. The orthopedic surgery team documents that the fluid was clear and nonpurulent but could not be analyzed further. The patient was given supportive treatment with anti-inflammatories and pain medications, and gradually improved. Within 24 hours of hospitalization, the orthopedist had a low suspicion of septic arthritis. The patient remained afebrile. The inflammatory markers are typically elevated in rheumatologic and infectious conditions and are very nonspecific. The patient's pain was controlled with oral narcotic medications and steroids. Based on these findings, I find no clinical indications to admit this patient under the inpatient level of care. It was reasonable to monitor the patient under an alternate level of care, to ensure no joint infection.