Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left hip pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with past medical history of osteonecrosis of the left femoral head, asthma, gastroesophageal reflux disease, cocaine abuser, and current smoker. He presented to the emergency room with complaints of left hip pain status post mechanical fall.  It was noted that he has fallen three times at home in the prior month, and he was unable to walk.  It was noted that he injured the left wrist during the fall and reported pain.

The patient's radiological studies revealed the following: 
CT of the pelvis showed advanced degenerative changes in the left femora-acetabular joint; linear lucencies in the left femoral head could represent acute nondisplaced fracture. X-ray of the left hip showed severe osteoarthritis of the left hip with possible AVN (avascular necrosis) of left femoral head, there was no acute bony fracture or dislocation. X-ray of the left femur showed no evidence of acute fracture; there was severe osteoarthritis of the left hip with findings concerning for avascular necrosis of the left femoral head. X-ray of the left knee showed no evidence of acute fracture or dislocation, prepatellar soft tissue swelling was noted, osteoarthritis of the left knee. X-ray tibia fibula left showed mild degenerative changes.  Chest x-ray showed no pulmonary infiltrates, severe degenerative changes in the right shoulder and surgical clips right upper quadrant.

Orthopedic service was consulted for left hip pain.  The patient denies loss of consciousness and head trauma.  Vitals included blood pressure 143/84, temperature 98.2C, pulse 74, respiratory rate 18, and oxygen saturation 98% on room air.  Examination noted pain with range of motion of the shoulder, tenderness to palpation over the left trochanteric area; he was able to flex the left hip to 45, otherwise grossly unremarkable exam.  Assessment by orthopedic service was significant osteoarthritis of left hip, and osteonecrosis of left femoral head; no acute orthopedic intervention was recommended.  It was noted that the patient will be referred to arthroplasty surgeon to discuss total hip arthroplasty.  He was to return to orthopedic joint clinic.
Evaluation by physical medicine rehabilitation recommended bedside PT (physical therapy), and pain management. 

Discharge summary noted diagnosis of gait instability, osteonecrosis, left hip pain, fall and osteoarthritis of left hip.  Physical therapy recommended short-term rehabilitation.  The patient remained hemodynamically stable throughout the hospitalization.

No, the Inpatient admission was not medically necessary.

The patient was admitted to the hospital following a fall with left hip pain.  He was noted to have gait disturbance.  Orthopedic consultation was sought; impression was significant osteoarthritis of left hip, and osteonecrosis of left femoral head; no acute orthopedic intervention was recommended.  He was asked to follow in orthopedic joint clinic.  However, the patient received care in the hospital for gait disturbance, including bedside physical therapy.  Throughout the admission, it was noted that he remained hemodynamically stable. There was no evidence of sepsis, osteomyelitis, loss of consciousness, acute head trauma, significant electrolyte imbalance, acute fracture or dislocation requiring inpatient management. 

In view of the foregoing, the proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.