Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain and swelling (to the left arm)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male teen with medical history significant for eczema and mild persistent asthma that presented to the emergency department with left arm pain and swelling. He had been working out vigorously the day prior including an hour of weightlifting and several hours of walking on a treadmill. The pain was located over the biceps and was worse with arm extension at the elbow.

The patient's vital signs included temperature 36.5, heart rate 97, respiratory rate 18, and blood pressure 137/74. Examination was significant for regular heart rate and rhythm, clear lungs, benign abdomen, edema and tenderness of the proximal left upper extremity, strong radial pulses and intact sensation, strong grasp, and non-focal neurologic exam. Laboratory evaluation was significant for elevated aspartate aminotransferase (AST) (43), elevated alkaline phosphatase (204), elevated lactate dehydrogenase (LDH) (272), and elevated creatine phosphokinase (CPK) (3565). Urinalysis was unremarkable. Coagulation studies were slightly elevated. Electrocardiogram was unremarkable. The patient was treated with a normal saline bolus and Tylenol. He was diagnosed with non-traumatic rhabdomyolysis and admitted for hydration and monitoring for compartment syndrome. 

Admission orders included monitoring arm circumference every four hours, consideration for ultrasound with subsequent surgery should compartment syndrome be identified, neurovascular monitoring hourly, ibuprofen as needed for pain, repeat lab studies every eight hours, aggressive parenteral hydration, regular diet, cardiac monitoring with vital signs every two hours, and consideration for vaccinations at discharge. 

Overnight, neurovascular checks remained within normal limits. The patient did not require any medication for pain. The redness decreased as well as the tenderness. The patient's arm circumference remained stable. The intravenous fluids were changed to half-normal saline with added bicarbonate to facilitate resolution of elevated creatine phosphokinase (CPK). The patient was voiding without difficulty and slept on and off. Creatine phosphokinase peaked at 5208 at night and in the morning was 5202. The patient remained on fluids to facilitate wash-out. 

The following day, the pain had resolved. The patient's creatine phosphokinase (CPK) was trending downward, less than 5000 with normal electrolytes and creatinine. The patient was deemed stable for discharge with instructions to continue aggressive oral hydration. He was given prescriptions for his asthma medications, and he declined vaccinations.

No, the acute inpatient admission was not medically necessary.

Rhabdomyolysis is generally defined as an elevation of serum creatine kinase activity at least ten times the upper limit of normal followed by rapid decrease to normal. It occurs when skeletal muscle is broken down, releasing electrolytes and myoglobin into the circulation. Rhabdomyolysis may be caused by substance abuse, medications, trauma, or seizures. It may also be virus-associated, with the most common virus being influenza. Clinical findings include myalgia, weakness, and pigmenturia, but less than ten percent of patients present with this triad. The most concerning complication is acute kidney injury, although arrhythmias from electrolyte abnormalities also are a source of morbidity. Acute renal failure may occur as a result of acute tubular necrosis when myoglobin causes obstruction in the kidney. This typically occurs with creatine kinased (CK) (creatine phosphokinase) levels greater than 16,000. Initial treatment is aimed at preserving renal function, managing electrolyte derangements, and aggressively maintaining hydration.  

This patient presented with acute pain and swelling of the left upper extremity following a prolonged work-out. Laboratory evaluation revealed rhabdomyolysis, with creatine phosphokinase over 3000. His renal function was within normal limits. He was given intravenous fluids and was admitted for ongoing hydration and monitoring for compartment syndrome. While it was reasonable to monitor for this devastating complication, this patient was hemodynamically stable without severe pain requiring parenteral pain medications, with good urine output and normal renal function. He did not require acute inpatient admission and could have been safely and appropriately managed in the hospital at observation level of care.

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