Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral leg pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is an adult with a history of non-ST (interval on an ECG) elevation myocardial infarction (NSTEMI), hypertension, schizophrenia, and polysubstance abuse. 

She was brought to the Emergency Department (ED) for bilateral leg pain. The patient stated that the pain was constant in the left hip radiating distally, and the patient was unable to bear weight. Vascular surgery evaluated the patient, and the patient was admitted for pain control and anemia requiring transfusion. A Computed tomography (CT) angiogram showed decreased opacification in the left lower extremity arteries and intravenous (IV) opioids were given as needed for pain management as per anesthesiology. Orthopedics was also consulted. 

The patient was noted to have an acute swollen and tender left knee; Rheumatology was consulted, and the knee was drained. She was previously hospitalized at another hospital but refused Interventional Radiology (IR) drainage of that knee. 
"Adults commonly present to their family physicians with hip pain, and diagnosing the cause is important for prescribing effective therapy. Hip pain is usually located anteriorly, laterally, or posteriorly. Anterior hip pain includes referred pain from intra-abdominal or intrapelvic causes; extra-articular etiologies, such as hip flexor injuries; and intra-articular etiologies. Intra-articular pain is often caused by a labral tear or femoroacetabular impingement in younger adults or osteoarthritis in older adults. Lateral hip pain is most commonly caused by greater trochanteric pain syndrome, which includes gluteus medius tendinopathy or tear, bursitis, and iliotibial band friction. Posterior hip pain includes referred pain such as lumbar spinal pathology, deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, and hamstring tendinopathy. In addition to the history and physical examination, radiography, ultrasonography, or magnetic resonance imaging may be needed for a definitive diagnosis. Radiography of the hip and pelvis should be the initial imaging test. Ultrasound-guided anesthetic injections can aid in the diagnosis of an intra-articular cause of pain. Because femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes, advanced imaging and/or early referral may improve patient outcomes". (Chamberlain R., 2021).

"Osteoarthritis (OA), also known as degenerative joint disease, primary OA, wear-and-tear arthritis, or age-related arthritis, is a leading cause of disability in the US and worldwide. Clinicians use the word arthritis to mean inflammation of the joints. In public health sectors, arthritis is a blanket term used to refer to more than 100 rheumatic diseases and conditions that affect the joints, the tissues surrounding the joints, and other connective tissue. OA is the most common joint disorder in the US. The number of people affected with symptomatic knee OA is likely to increase because of the aging of the population and the obesity epidemic". (Lespasio MJ., et al., 2017).                                                         

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.