Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Increasing pain, redness, warmth to touch and bleeding of the right foot
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult male who presented to emergency department (ED) with increasing pain, redness, warmth to touch and bleeding of the right foot. He had a previous episode of bleeding, varicosities with stitches in place from a recent emergency department visit. The patient's medical history included asthma, opioid use diagnosis currently in methadone program with daily dose of 65 milligrams methadone, bilateral lower extremity varicose veins (not on anticoagulant).

On physical examination in emergency room, the patient's vitals were: temperature (T) 98.9, pulse (P) 83, respiratory rate (RR) 16, blood pressure (BP) 117/65, and pulse oximetry 96%. The patient had bitemporal cachexia, bilateral lower extremity edema, right lower extremity with two non-absorbable sutures in place on the anterior lateral aspect of the foot, non-bleeding, with three centimeters surrounding erythema, tender to touch. The patient was ambulatory with use of a cane. 

Laboratory studies were significant for hemoglobin 6.6, hematocrit 22.1, and lactic acid 1.7. A computed tomography (CT) of the right lower extremity showed severe varicosities in the right lower extremity, dilated greater saphenous vein with aneurysm at the level of the knee with eccentric filling defect compatible with chronic thrombus. There was diffuse soft tissue edema and skin thickening from the distal thigh to the ankle consistent with cellulitis.

The patient was admitted and given antibiotics. In the emergency department, the patient received Ceftriaxone 1000 milligrams intravenously (IV). On admission, the patient was placed on Ancef 1000 milligrams intravenously every eight hours, doxycycline 100 milligrams every 12 hours, Venofer 200 milligrams intravenously daily, methadone 65 milligrams daily, and pantoprazole 40 milligrams daily.

During admission, the patient was agitated and requested to sign out against medical advice (AMA) but agreed to receive blood transfusion. He received one unit packed red blood cells (PRBCs). The patient requested to leave and was discharged home for outpatient follow up.

The proposed inpatient hospital admission was not medically necessary.

For the duration of the hospital stay the patient was afebrile and had stable vital signs.  The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. The patient's physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Additionally, on presentation he did not have signs of sepsis to indicate continued need for intravenous antibiotics. The patient could have been transfused packed red blood cells (PRBCs) in the emergency room and could be continued on oral antibiotics after initial intravenous antibiotic administration in the emergency room. 

The patient's diagnosis had been established clinically and based on the results of the investigations. The patient was hemodynamically stable and afebrile. For the above duration, the patient had stable vital signs and routine labs remained at baseline. 

Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates. In view of these findings, the ongoing inpatient level of care for the above duration was not medically necessary.