Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Poorly controlled diabetes mellitus, hypertension, deep venous thrombosis, cellulitis

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission

The denial is: Upheld

This case is regarding denied coverage for hospital admission. The patient had a medical history significant for hypertension (HTN), diabetes mellitus, recent COVID-19, and poor medication compliance. Records stated the patient was admitted recently with secondary deep vein thrombosis and cellulitis. The patient was placed on Eliquis and discharged but was noncompliant with oral anticoagulation and treatments were limited by social determinants. The patient declined subacute rehabilitation and was found by homeless outreach staff. The patient was placed on intravenous (IV) antibiotics but then requested to be discontinued and placed on oral and was subsequently discharged to the shelter. The patient presented to the Emergency Department (ED) complaining of worsening left lower extremity pain. The patient was provided with a wheelchair on discharge but had difficulty managing due to pain and immobility, prompting the return to the ED for further evaluation and management (E/M). At the time of the assessment, the left lower extremity was red, warm, and tender to palpation. The patient was unable to ambulate due to pain and had abnormal laboratory values to include platelets at 577, glucose 304, lactate 1.6, and C-reactive protein at 138.00. An ultrasound of the left gastrocnemius vein revealed acute occlusive deep vein thrombosis (DVT). The blood pressure was 169/100, pulse at 97, respirations 17, temperature 98, and saturation of peripheral oxygen (SpO2) at 100%. Following initial treatment, the blood pressure stabilized to 144/90. The patient was subsequently admitted to inpatient MedSurg level of care. The patient continued to endorse left lower extremity pain but refused intravenous and subcutaneous medications, but was agreeable to oral antibiotics, diabetic medications, and medications were adjusted accordingly. The patient was given oral Roxicodone 5 milligrams (mg) x 1.  The patient refused skilled nursing facility placement and was safely discharged to a shelter once deemed medically stable by the attending physician.


According to the Milliman Care Guidelines, admission to inpatient care may be indicated for those individuals who are hemodynamically unstable, have altered mental status that is severe or persistent, have a limb threatening infection, clinical presentation (e.g., acuity of infection, rapidity of progression) or treatment regimen is judged to require intensity of patient monitoring (e.g., vital sign measurement, checks for infection progression, laboratory testing) that cannot be provided at other than inpatient level of care, bacteremia, suspected necrotizing soft tissue infection, severe oral or head and neck cellulitis, orbital infection, preseptal or perennial infection that is severe or progressive, severe pain requiring acute inpatient management, inability to maintain oral hydration that persists after observation care, or when the patient has a need for compartment syndrome monitoring. Alternatives to admission include outpatient care, observation care, home care, or a recovery facility. The evidence did not suggest that the patient cannot be safely and effectively treated on an observational basis initially with the availability of moving to inpatient status if necessary. Given the provided documentation, the hospital 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 hospital admission is not substantiated.