Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Ankle Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history significant for asthma and polytrauma sustained after a fall from a height who presented to the emergency department with complaints of acute on chronic left/ankle pain. 

It was reported that the patient underwent several surgical procedures involving his left ankle and foot. Since that time, he had chronic pain, which was 5/10 in intensity at the baseline. Over the course of several weeks, he noticed increasing pain that was exacerbated by movement and had partial relief after taking Oxycodone. The patient stated that because of the pain he was unable to walk or care for himself. He reported occasional swelling and stiffness but denied a fever, recent trauma, other joint swellings, or rash. In the emergency department, the patient was afebrile. 

The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. There were chronic skin changes/scarring in the interior shin bilaterally with no erythema, warmth, drainage, or petechiae. 
The patient was admitted to the hospital with acute and chronic left/ankle pain, status post previous left subtalar fusion. 
In the hospital, the patient was seen by an orthopedic surgeon who had a low suspicion of infection or acute trauma. Additional imaging studies, such as an x-ray of the right foot/ankle/tibia, were recommended. Pain control with nonsteroidal anti-inflammatory drugs (NSAIDs), Lyrica, and pain management referral were also recommended. There was no need for acute orthopedic intervention. 
The x-ray of the left foot was performed and demonstrated subtalar fusion with well-fixed hardware and bridging callus. There was some lucency around the hardware, which apparently was chronic. There was no evidence of hardware failure. X-ray of the left tibia showed no fractures or dislocations. In the hospital, the patient was seen by a pain management specialist who recommended treatment with Percocet, Lyrica, Diclofenac, and Amitriptyline. 
During the hospital stay, the patient remained afebrile and hemodynamically stable and was discharged from the hospital the next day after the day of admission. At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. 
Based on the clinical evaluation, there was no evidence that the patient had an infection in the bone or hardware requiring treatment with intravenous antibiotics. There was no evidence of a new fracture, dislocation, or any other musculoskeletal injury requiring inpatient care. There was no mention that the patient had a recent major injury or a limb-threatening injury. 
There was no evidence that the patient had pain severe enough that would justify admission for acute inpatient management. In addition, there was no evidence that the patient's symptoms were related to severe crystal arthropathy, severe myopathy, vasculitis, or any other severe rheumatologic disease. 

Therefore, a lower level of care was most appropriate given the clinical circumstances, in order to rule out acute medical conditions requiring treatment in acute inpatient settings as well as for adjusting his pain management regimen. Neither the severity of the patient's condition nor the complexity of the hospital admission rose to the acute inpatient level of care.