Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	Foot pain	
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This case involves an adult with a request for inpatient hospital admission. The patient was seen at the emergency room (ER) with a history of gout on home allopurinol, end stage renal disease with a plan to begin hemodialysis soon, chronic obstructive pulmonary disease (COPD), coronary artery disease, dyslipidemia, brain tumor, hypertension, asthma, and 2 days of severe right foot and ankle pain. The patient also reported shortness of breath and left sided chest pain that began the day prior but had resolved. On exam, swelling and redness were noted in the right ankle and foot, with painful range of motion in the first toe and ankle. The patient was also stated to have an initial blood pressure of 155/97, as well as a small left conjunctival hemorrhage. Lab work revealed low hemoglobin, elevated blood urea nitrogen (BUN) and creatinine. It was noted that the patient became nauseous and began vomiting after she was provided steroids and allopurinol and was unable to be given non-steroidal anti-inflammatory drugs (NSAIDs) or colchicine. The patient was admitted for intravenous (IV) steroids and pain control and underwent a Rheumatology consult for acute exacerbation of gout. It was noted that allopurinol was discontinued and a low dose of febuxostat was started. The patient underwent renal consult for chronic kidney disease. It was noted that the patient had a left forearm arterio-venous (AV) fistula and denied urinary complaints and uremic symptoms. The patient was noted to have a BUN of 83, creatinine of 4.4, hematocrit of 30.3, and hemoglobin of 9.8. The patient reported that creatinine was always in the 4's. The patient was determined to be stable, with stage 5 chronic kidney disease. The treatment plan included outpatient follow-up visit, starting steroids for acute gout, continuation of home medication regimen, and starting a renal diet. The patient reported continued but improved right ankle and foot pain with a pain level of 5/10. The patient was noted to have improved acute gout exacerbation, asymptomatic end stage renal disease, and stable coronary artery disease. The treatment plan included continuation of medication regimen and discharging the patient home when medically cleared. The patient reported improved pain from admission. It was noted that the patient was on a short-term course of prednisone 40 milligrams (mg) for 3 days. The patient was cleared for discharge. 

Milliman Care Guidelines indicates admission to inpatient care for patients with severe crystal arthropathy that requires inpatient care, as indicated by severe pain requiring acute inpatient management or exacerbation that requires inpatient treatment, such as IV treatment. Although the patient was noted to have a history of stage 4 chronic kidney disease with abnormal lab results, records indicate that the patient remained stable throughout the inpatient stay and did not require hemodialysis or other intensive inpatient treatments such as continued IV medications. The patient reported that her creatinine level was regularly in the 4's. Although the patient had nausea and vomiting with oral medications for gout pain, the records do not indicate that the patient received IV pain medications throughout her inpatient stay. While the patient had initial complaints of shortness of breath and chest pain the day prior to presenting to the emergency department, the symptoms were noted to have resolved on the first day with no significant abnormalities to necessitate the inpatient stay. The patient was stable and could have received care at a lower level of care for observation. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for inpatient admission is not substantiated.