Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient facility stay. The denial is upheld.

The patient is a male with a past medical history significant for hypertension who presented to the emergency department for evaluation of right upper extremity swelling and pain. Approximately two weeks before the presentation, his right arm started to swell. Specifically, the swelling was located in the biceps area. The patient had been seen at urgent care and by his primary care physician, who prescribed treatment with oral antibiotics that included Doxycycline and Augmentin. Reportedly, the swelling did not improve.
At the time of the initial evaluation, the patient denied any fever or chills.
His temperature was 98.1 Fahrenheit (F), pulse rate was 79 beats per minute (bpm), respiratory rate was 16, blood pressure was 174/100, and oxygen saturation was 95% on room air. The patient appeared to be a well-developed, well-nourished male who was not in acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound.
There was swelling in the right biceps and right forearm, as well as the right side of the breast.
The patient had difficulties with pronation and supination of the right upper extremity due to swelling. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 12.2, hemoglobin was 14.4, hematocrit was 41.9, and platelets were 353. Sodium was 135, potassium was 4.0, chloride was 96, bicarbonate (HCO3) was 24, blood urea nitrogen (BUN) was 20, creatinine was 1.1, and glucose was 92.
The patient was admitted to the hospital with a diagnosis of right arm cellulitis. The patient was started on intravenous broad-spectrum antibiotics, and orthopedic surgery consultation was requested.
The orthopedic surgeon recommended a magnetic resonance imaging (MRI) of the shoulder with contrast, to rule out an abscess and also to look for a tear of the muscle that may need operative fixation.
The MRI of the right upper extremity revealed a small biceps tear with no frank abscess or fluid collection. The patient's upper extremity was placed in a sling with warm packs.
Ultrasound of his right upper extremity was negative for deep vein thrombosis (DVT).
While in the hospital, the patient's clinical condition significantly improved. The leukocytosis resolved. The patient demonstrated significant improvement in the range of motion in his fingers and was able to supinate and pronate his arm. He was transitioned to outpatient care.

The inpatient facility stay was not medically necessary for this patient.

The patient was afebrile. In addition, on the exam, his skin had normal color, normal temperature. There was no indication that the patient had erythema or local warmth. Additionally, there was no improvement in his symptoms after he took the full course of appropriate antibiotics. The subsequent evaluation revealed a small bicep tear, the condition that explained all these symptoms.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Therefore, there is not overwhelming evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care.
The patient could have been managed at a lower level of care status.