Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Leg pain, numbness and weakness.
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission.
The denial is upheld. 

The patient is a male, who presented to the emergency department (ED) for left leg pain, numbness, and weakness. The patient reported the onset of pain 2 years prior due to a fall. The patient had a prior history of a lumbar (L)2-4 posterior fusion with L2/3 laminectomy and L3 corpectomy for treatment of an L3 burst fracture. He subsequently developed an epidural abscess requiring incision and drainage (I&D) and revision surgery. He was subsequently discharged to rehabilitation. The patient was receiving intravenous (IV) antibiotics via a peripherally inserted central catheter (PICC) line at the time of presentation.
At presentation, his physical exam was notable for right upper extremity (RUE) 4/5 strength due to pain, left hip 1/5 and left lower extremity (LLE) 2/5 which was described as his baseline. X-rays showed stable lumbar hardware and known left hip avascular necrosis (AVN). Orthopedic spine was consulted and an urgent (STAT) cervical, thoracic, and lumbar spine magnetic resonance imaging (MRI) was obtained as well as labs. These showed post-operative fluid collections. The patient was admitted and continued on IV vancomycin and meropenem. His pain was treated with oxycodone. Physical therapy (PT) was consulted and documented recommendation for home with (w/) home care versus (vs) sub-acute rehabilitation. Orthopedics was consulted for evaluation of his chronic left hip AVN. They recommended no surgical treatment given his ongoing infection and poor medical optimization. Infectious disease was consulted  (hospital day [HD] 7) and adjusted his vancomycin dosing. Hospitalist was consulted (HD 7) for co-management of chronic medical issues. Orthopedics was reconsulted (HD 9) for right upper extremity (RUE) weakness and right (R) shoulder pain status/post (s/p) R humeral nail. They recommended neurology evaluation and pain control with continued postoperative restrictions. Neurology was consulted (HD 10) for R hand numbness. They recommended an MRI of the brain and magnetic resonance angiography (MRA) of the head/neck to evaluate for a stroke. The patient was discharged to home (HD 13) with home care and IV antibiotics.
At issue is the medical necessity of the Inpatient Admission.

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

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient.
An inpatient admission is not medically necessary for this patient. Inpatient admission is generally indicated for a newly diagnosed infection and when IV antibiotics cannot be initiated. The patient had a preexisting infection that had not worsened, and IV antibiotics predated presentation. Imaging and labs suggested no new infection. The patient lacked any new fracture or injury requiring inpatient admission. The patient lacked any medical condition that required inpatient services. Care provided did not require an inpatient admission per the documentation.
Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary for this patient.