Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right hand and wrist swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented to the hospital with the chief complaint of right hand and wrist swelling with redness. His symptoms started two weeks prior, and were of gradual onset and progression to the point that he could not use his right hand and make a fist. He was right handed. He had a deformed left hand due to a childhood injury. As such, he reported problems doing his activities of daily living. The patient had no past medical history.

Examination of the patient's vital signs and general systemic exam were normal.  Right hand was swollen, tender and red. He could not make a fist and bend his wrist. White cell count and LFT (liver function test) were normal, but creatinine was elevated to 1.32 mg/dL (milligrams per deciliter). CRP (C-reactive protein) was 5, elevated and ESR (erythrocyte sedimentation rate) was 75, also elevated. X-ray of the right hand revealed soft tissue swelling in the right hand without overt osteomyelitis or deep tissue involvement. The diagnoses were acute kidney injury due to ibuprofen use at home for pain, and right hand cellulitis with no history of trauma.

The patient was given Unasyn and admitted to the hospital. Orthopedics consult was obtained. The physician indicated an anticipated need for inpatient services. The case was denied by insurer based on "There was no indication of hemodynamic instability, infection or a systemic condition requiring inpatient care." The appeal submitted by the hospital indicated that admission was indicated due to cellulitis with acute renal failure and intractable pain that was worsening and could not be treated in the outpatient setting.

No, the Inpatient admission was not medically necessary.
The patient was a middle-aged, otherwise healthy male with no known underlying medical conditions.

The patient's renal insufficiency was mild, and underlying renal function / creatinine were unknown. The assumption that the patient had acute renal failure is not justified based on lack of oligo-anuria, creatinine above 4 mg/dL (milligrams per deciliter), electrolyte abnormalities, acid base abnormalities, increased anion gap, lactic acidosis or diminished bicarbonate, fluid over load or findings of uremia or pericarditis / pleuritis.

Although the patient had pain, this was well-managed with Toradol and oral opioids with improvement within the first 24 hours of care.

The patient did not have any organ dysfunction, a low sepsis risk score, low qSOFA (quick sequential organ failure assessment) and lack of fever or leukocytosis. Although he had initial tachycardia, he did not have documented persistent tachycardia at rest.

No local findings of compartment syndrome were present - radial pulses were normal. There were no findings of gas in tissues on X-ray, and no clinical findings of bulla, violaceous discoloration, crepitus, blebs or petechiae / purpurae or cutaneous gangrene to suggest necrotizing infection. No pain out of proportion to the findings was noted.

In summary, the patient lacked risk factors for rapid progression in the form of underlying conditions such as uncontrolled DM (diabetes mellitus) or immune compromise, had no systemic abnormalities suggesting systemic inflammatory response syndrome or sepsis, and no local findings indicating necrotizing or rapidly progressive infection. There was also rapid improvement in the first 24 hours. Interventions did not include surgery, laminar air flow, ICU (intensive care unit) level care and other indicators of unusual intensity. Renal insufficiency was mild and only required a day of IV (intravenous) fluids for reversal. Therefore, given the above, the patient could have been treated in an observation setting.