Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

The patient is a female with psychiatric diagnoses who presented with worsening arm pain. She was well until about a month prior to presentation when she developed pain in the left forearm, from her elbow to the tip of her fingers. The pain was intermittent, up to a 7 out of 10 in intensity. The pain continued until the night of presentation, when it increased in severity up to 9 out of 10 and was unrelenting and not responsive to ibuprofen. She had left arm weakness, as well as numbness and tingling of her fingers and a transient rash of the left forearm. She described headaches, as well as photo and phonophobia.

In the emergency department, she was lying in bed holding her arm and crying. She had tenderness to palpation of the forearm with no overlying erythema or edema, good pulses, and normal capillary refill. Sensation was mildly decreased on the radial aspect of the anterior left forearm and palm. An x-ray of the left upper extremity was unremarkable. She received morphine times (x) 2, Toradol x 2, and acetaminophen with some relief. She was also given gabapentin. She was seen by neurology. They recommended a magnetic resonance imaging (MRI) scan to rule out a vascular event and an electromyography (EMG). After treatment, she continued to have pain of 7/10 in intensity. She was therefore admitted for further evaluation and pain control.

In the hospital, she was continued on Gabapentin, which was titrated up during the hospitalization to 300 milligrams (mg) three times per day (TID) due to continued pain. She also described some neck pain. The MRI scan and EMG studies were normal. Psychiatry and social work were also consulted due to social and psychiatric issues. She was diagnosed with tinea versicolor and selenium sulfide was prescribed. She improved with treatment over time and was ultimately diagnosed with complex regional pain syndrome. She was felt to be stable for discharge to home with follow up in occupational therapy and an EMG as an outpatient.

At issue is the medical necessity of the inpatient hospital admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient hospital admission was medically necessary for this patient.

This is a patient who presented with severe pain of her arm that was worsening and unrelenting. She was in extreme pain at the time of presentation, holding her arm and crying, which was only somewhat relieved with treatment. She had tenderness of the arm and neurologic symptoms including weakness and numbness. She was appropriately and promptly evaluated and treated in the emergency department setting, but she continued to have pain of 7/10 in intensity and her diagnosis was not clear. She required hospitalization for ongoing evaluation recommended by the specialist team, as well as management of her severe pain. She required inpatient admission for pain control, titration of medications, complete evaluation, and specialist consultation.

The decision making at the time of admission for this patient was consistent with her young age, the presence of severe acute on chronic arm pain and neurologic symptoms, and the need for prompt initiation of pain control and full evaluation to ensure appropriate management and prevent further morbidity.

Therefore, the inpatient hospital admission was medically necessary.