Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot ulcer.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with a past medical history of diabetes, neuropathy, hypertension, and heart disease. She presented to the ER (emergency room) for an 
infected right diabetic foot ulcer. She was in the hospital two months prior for over seven weeks due to third degree burns and osteomyelitis. She had been recently treated with Clindamycin and topical antibiotics after being seen at an urgent care. During the admission, she was treated with IV (intravenous) antibiotics and was recommended by podiatry to obtain an MRI (magnetic resonance imaging). She left the hospital against medical advice.
The patient's hospital timeline is as follows:
Day of admission: Admitting WBC (white blood cell) count was 3.3, with a normal ESR (erythrocyte sedimentation rate) of 15 and CRP (C-reactive protein) of 2.12. Examination was notable for a right foot ulcer that was wrapped, as well as skin grafts to the back and left arm. X-ray of the right foot was suspicious for osteomyelitis. The patient received IV (intravenous) antibiotics in the ED (emergency department) and podiatry was consulted. Evaluation by podiatrist was notable for good pedal pulses and wounds on the right 4th and 5th toes. The wound was probed to the bone capsule without signs of infection. The patient was admitted for an infected right toe and for further workup. 
Evaluation by internal medicine was notable for a right 5th metatarsal foot ulcer.
The next day the Wound Nurse was unable to evaluate the wound, because the patient wished to leave the hospital against medical advice.

The inpatient admission was not medically necessary.

In this case, the patient did not have criteria for inpatient admission such as instability, fever, intractable pain, altered mental status, limb-threatening infection, need for surgical intervention, or failure of outpatient treatment. The patient's wound did not exhibit clinical signs of acute infection. Although imaging showed osteomyelitis, the patient was diagnosed and treated for osteomyelitis for seven weeks just a month prior. Inflammatory markers were normal, and the patient had no fevers. There was no indication of risk of an acute limb threatening infection or need for urgent surgery. Additional imaging could have been completed at a lower level of care basis. Imaging after recent osteomyelitis treatment can be false positive due to remodeling and due to neuropathic osteoarthropathy (Ref2). In addition, the sensitivity and specificity of bone x-rays are 75% (Ref3) for acute osteomyelitis. For chronic osteomyelitis as would be suspected in this case, MRI (magnetic resonance imaging) has an 84% sensitivity and FDG PET (fludeoxyglucose positron emission tomography) scan with WBC (white blood cell) scan is more specific at 91% (Ref 3). The imaging results would likely not be a true positive result, and the patient's clinical signs did not indicate inpatient treatment was required. Furthermore, the additional imaging could have been done as an outpatient. Consultations with podiatry and infectious disease could have also been done as an outpatient.