Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic foot ulcers, early osteomyelitis.
Treatment: Inpatient Hospital Stay.
The health plan denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of hypertension, diabetes, sleep apnea, and peripheral vascular disease. He was sent to the hospital by his primary care physician due to a diabetic foot ulcer, which had been present for three weeks, causing mild pain. The ulcer was present at the right hallux, atraumatic, without drainage or a foul smell. The patient had a prior admission and was released from a different hospital on oral antibiotic therapy. There are no reported fevers, shortness of breath, chest pain, palpitations, nausea, vomiting, or abdominal pain. The patient's diabetes is controlled with metformin and he is not on insulin.
On admission, his vital signs were stable, with a heart rate of 90 and blood pressure of 106/71. On exam, the cardiopulmonary findings were unremarkable. On skin exam, the patient had an amputation of the left toes and right hallux ulcer, which appeared superficial with no clinical signs of infection. There was no warmth or discoloration.
Laboratory studies showed mild hyponatremia at 127, potassium at 5.4, and creatinine at 1.4. The white blood cell count was 5.6. A twelve-lead electrocardiogram (EKG) showed normal sinus rhythm. An x-ray of the right foot showed the soft tissue swelling with irregularity of the first digit, corresponding to a known ulcer. There was no definite cortical erosion or osseous destruction.
Upon assessment in the emergency department (ED), the patient was given a dose of cefazolin and Kayexalate for mild hyperkalemia. 6 units of lispro were given for an elevated blood glucose of 335.
The medical team ordered ankle brachial index (ABIs), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels and placed the patient on aspirin and statin. Infectious disease was consulted to assess the patient. The home medications were continued. Urine electrolytes were also ordered due to a diagnosis of acute kidney injury. The baseline kidney function is not documented. They started the patient on low-dose normal saline and ordered a renal ultrasound.
Podiatry assessed the patient on the day of admission and documented that the patient had skin breakdown on the medial aspect of the right hallux, which has been progressively worsening. A recent assessment at a different hospital showed no evidence of osteomyelitis, and the patient was discharged on Augmentin. They applied Betadine to the right foot and did not feel the patient had signs of infection. They noted that the patient's diabetes is uncontrolled, with an A1c of 14, and recommended tight glycemic control and perhaps an endocrinology consultation. Endocrinology assessed the patient started long-acting insulin plus short-acting insulin with meals, with further adjustments to be made.
The infectious disease specialist assessed the patient, noting stable white blood cell counts, mildly elevated CRP, and ESR, with normal lactic acid levels. Blood cultures were negative times (x) 1 day. On their exam, they noted some fluctuance in the superior aspect of the toe proximal to the ulcer. This started the patient on Rocephin, vancomycin, and Flagyl, as well as magnetic resonance imaging (MRI) of the right foot.
The patient's vital signs were stable, the glucose was improved to 95, therefore, the insulin dose was decreased from 25 units to 15. The urine electrolytes showed a decreased urine potassium and chloride without microalbuminuria. The blood cultures remained negative.
The patient remained in the hospital with no acute overnight events and stable vital signs. Blood glucose values started to trend up; therefore, the insulin dose was adjusted.
The patient had spent four days in the hospital, and there was still no ABI report per the medical team documentation. Blood cultures had remained negative for three days, and the endocrinologist made minor adjustments to the insulin. The magnetic resonance imaging (MRI) and the ABIs were performed. The MRI showed signs of early acute osteomyelitis and adjacent soft tissue swelling suggestive of cellulitis. The ABIs showed mild femoral-popliteal disease and moderate tibial disease bilaterally. Podiatry recommended hyperbaric oxygen therapy. The physical exam was unchanged. A venous duplex ultrasound was also performed, which showed no evidence of deep vein thrombosis (DVT).
The infectious disease specialist decided to continue intravenous antibiotics via a peripherally inserted central catheter (PICC) for six weeks on discharge.
Five days later, the patient remained in the hospital, the PICC had not been placed yet, and was not scheduled to be placed for an additional two days for unclear reasons. He was seen by vascular surgery, who documented strong distal pulses on their exam, reviewed the lab results and noted a normal white blood cell count, and scheduled an angiogram.
The angiogram was performed without complications and showed a 10-centimeter (cm) segment of near occlusive stenosis in the distal right superficial femoral artery, patent below the knee popliteal and anterior tibial arteries. The procedure report showed that angioplasty was performed through the stenotic segment, with post angioplasty revealing excellent results. There was no evidence of distal embolization. The vascular surgeon recommended dual antiplatelet therapy on discharge. The infectious disease specialist switched the patient to Teflaro. On recheck by vascular surgery, there were no complications from the angioplasty; the patient tolerated a diet and has no complaints. The medical team documented a plan of a now significant delay in placing the PICC. By this date, the patient had spent 18 days in the hospital and was still awaiting a PICC line. The patient was released home with IV (Intravenous) antibiotics 20 days after the initial hospitalization. 
At issue is the medical necessity of an inpatient stay.

The inpatient stay is medically necessary.

Based on the documentation provided, the patient had poorly healing diabetic foot ulcers with uncontrolled diabetes and early osteomyelitis that required a revascularization treatment. This is an inpatient admission, which cannot be managed at a lower level of care. Although this length of stay was fairly excessive for this type of presentation, due to delays in testing, inpatient admission criteria are met. The patient has early osteomyelitis, a poorly healing diabetic foot ulcer, with uncontrolled diabetes, A1c of greater than 14, requiring initiation of insulin. The patient had significant peripheral arterial disease, with stenosis, preventing the diabetic foot ulcer and osteomyelitis from healing properly, requiring a revascularization procedure. These are hallmark criteria for inpatient admission.
The medical literature supports this decision, and representative articles are included below.