Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis
 
Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial is reversed. 

This patient is a male admitted for recurrent osteomyelitis of the right foot. Based on the records provided, the patient has uncontrolled type 2 diabetes and history of right foot osteomyelitis that required multiple amputations. He had a right 1st ray partial amputation in 2018 and a right 2nd digit amputation in 2019. According to the patient's report, he completed his 7 days course of Augmentin after the 2019 amputation, but the surgical wound from the amputation never healed in the past 3 months. Rather, the patient states that the pain at the amputation site increased from minimal at the time of the 2019 discharge to 9/10 in severity. He has also noticed his 3rd and 4th toes starting to turn black about 6 days prior to this presentation. He states that he has not followed up with the podiatrist since discharge. The patient also states that he has not been taking any of his insulin and has not seen a doctor in some time.

At the emergency department, the patient had an elevated heart rate of 106, leukocytosis of 15.6K/uL, and a blood glucose level of 470mg/dL. CT scan of the right foot showed osteomyelitis of the second proximal phalanx with multiple foci of air. Podiatry consult noted that the patient had right foot gas gangrene. The Podiatry team performed a bedside incision and drainage (I&D), and recommended surgical intervention. Based on the result of the MRI of the right foot, Podiatry's plan was to perform either a right foot transmetatarsal amputation (TMA) or a partial 2nd ray amputation. Vascular consulted  in this case because of physical exam findings (i.e. cool to touch and dusky appearance) concerning for vascular insufficiency of the right foot/toes. Based on the Vascular Surgery evaluation for arterial insufficiency, Vascular Surgery recommended surgery after the patient's podiatry procedure. His HBA1C was >18.5. He received broad spectrum IV antibiotics. 

Based on the deep wound culture from the Podiatry I&D procedure, patient has multiple, heavy growth of bacterial organisms infecting his right foot. Based on ED evaluation, patient was a high risk for antibiotic-resistant osteomyelitis. He was treated with outpatient antibiotic after the 2019 amputation but condition did not improve. The patient's pain and wound condition worsened. This failure of outpatient treatment and the development of foot gas gangrene (necrotizing soft tissue infection) of the right foot was a limb-threatening infection.

The Journal of Hospital Medicine also supports the medical necessity of this patient's inpatient admission. According to Thurber et al (2017) article, the Infectious Diseases Society of America (IDSA) and the International Working Group on the Diabetic Foot (IWGDF) guidelines recommend hospitalization for patients with severe infection (i.e. this case patient's gas gangrene right foot), moderate infection with certain complications (i.e. this case patient's vascular insufficiency and lack of home support), an inability to comply with required outpatient treatment (e.g., this case patient's noncompliance to insulin/diabetic treatment), lack of improvement with outpatient therapy (e.g., this case patient's surgical wound refractory to outpatient antibiotic, Augmentin), or  the presence of metabolic instability (i.e. this patient's uncontrolled diabetes/glucose). This patient required surgical debridement (e.g., incision and drainage) and broad antibiotic coverage due to risk of antibiotic-resistant organisms.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.