Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain and swelling to the right foot
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He presented with pain and swelling to the right foot. The patient's right lower extremity had started to swell two weeks prior to presentation and had progressively worsened over the last week before presentation to ED (emergency department). The patient denied any systemic symptoms. The patient denied something similar happening before, but the patient had been discharged from the ED for right lower extremity swelling and pain after a fall. Also, he was admitted in past for left lower extremity pain and swelling and was treated with antibiotics.

The patient denied fever, chills, nausea, vomiting, diarrhea, chest pain, palpitation, shortness of breath (SOB), abdominal pain, dysuria, dizziness or headache. The patient's vitals in the emergency room showed T (temperature) - 37.6, BP (blood pressure) 106/77, P (pulse) 75, R (respiration rate) 18, and Pulse oximetry 98% (percent).

The patient was given Tylenol in the ED. His labs were unremarkable for any significant abnormalities - WBC (white blood count) 8.4, Hb (hemoglobin) 11.1 and acceptable chemistry values. His ultrasound was negative for DVT (deep venous thrombosis), and x-ray right foot and ankle did not show fracture. CT (computed tomography) scan of right lower extremity did not show rim enhancing fluid collection suspicious for abscess and there were no osseous changes concerning for osteomyelitis.

No, the inpatient admission was not medically necessary.

Inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk is based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition.

The patient was started on IV (intravenous) clindamycin and heparin subcutaneously every 8 hours.

When the patient in this case presented to the ED, the patient was afebrile and with stable vital signs. The patient was hemodynamically stable. The patient had not been treated with oral antibiotics/failed outpatient treatment with oral antibiotics before presentation to the ED. On presentation, the patient did not have any history of fever, nausea, vomiting, diarrhea or abdominal pain or SOB. Investigations completed showed normal WBC count, no evidence of DVT on sonogram, CT scan ruled out abscess or osteomyelitis, and x-ray was negative for fracture. Labs did not show elevated WBC count or other major abnormalities to necessitate inpatient hospital stay. The patient did not have any comorbid conditions that may have required inpatient stay. EKG (electrocardiogram) showed findings that may have indicated presence of left ventricular hypertrophy, however there were no other changes to indicate acute coronary event that may necessitate inpatient 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. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the duration, there were no new investigations ordered/work up initiated, and there was no change in management plans that would justify/necessitate continued inpatient stay in the hospital. During the above duration, the patient's diagnosis had been established clinically and based on the results of the investigations. The patient was hemodynamically stable and afebrile. The patient's temperature and other vital signs were not representative of sepsis during this time. General and systemic examination was normal or at baseline. The patient was able to eat food, drink fluids and take oral medications. Although the patient had pain, it was not intractable, and not noted to not be amenable to appropriate oral treatment. Care rendered during this time was of low intensity, routine nursing and physician monitoring. No systemic findings such as high fever, shock, renal or liver failure or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. No high frequency, high complexity, or high risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness on presentation and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, inpatient care was not medically necessary for the above dates.

Therefore, in view of these findings, and generally in accordance with MCG (Milliman Care Guidelines) guidelines, the inpatient level of care for the above duration was not medically necessary.