Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pressure ulcers 

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission.
 
The denial is upheld.

This case involves then a male who was transported via the Emergency Medical Services (EMS) to the hospital with chief complaints of pressure ulcers. The patient was alert and oriented, and was complaining of bedsores to multiple areas. The patient had a recent discharge (2 weeks prior to this ED presentation) from a rehab center after several months of admission. The patient reported that he was bedbound and was unable to transfer into and from the wheelchair. The patient had refused to comply with physical therapy and refused to comply with home health.  The triage documentation indicated that the patient was afraid to stand and reported that his left leg had been feeling numb for months.  The patient stated his ulcers were worsening and that he was not able to get up and walk. On exam, the patient was obese with 2 stage I decubital ulcers on the left buttocks; there was 4 out of 5 strength to the left lower extremity and 5 out of 5 strength to the right lower extremity; there was intact sensation to light touch to the upper and lower extremities.  The documentation detailed the patient was previously seen and had undergone a magnetic resonance imaging (MRI) that showed no compression or cauda equina.  It was recommended that the patient undergo laboratory studies due to the inability to tolerate physical therapy at home and recent discharge from subacute rehabilitation.  

The patient's laboratory studies revealed white blood cell count of 13.4 with hemoglobin at 10.0 and hematocrit 33.7.  The patient's glucose was 221.  The physician indicated that the patient would likely need placement to a rehabilitation facility, but was unable to obtain the placement overnight.  The physician wanted to keep the patient until the following morning for case management disposition.  The patient was thus, admitted. During this inpatient stay, the patient received physical therapy (PT) sessions and wound care. The patient was also evaluated by neurology and internal medicine specialists.  The patient's cervical magnetic resonance imaging (MRI) revealed disc disease most pronounced at the C6-7 level where there was mild to moderate bilateral neural foraminal narrowing with moderate canal stenosis.  The patient did not have any further significant abnormalities.  The patient had a negative neurological work-up and it was recommended that the patient be discharged.  It was noted within the documentation submitted that home arrangements were made for the patient to receive a hospital bed.  The patient was also discharged with a physical therapy referral. 

According to literature review, patients with stage III or IV pressure ulcers may be clinically indicated for hospitalization to undergo procedure, especially if there is documentation that prior therapy has been trialed and failed. However, in this case, this patient had stage 1 pressure ulcers that did not required inpatient treatment. The patient's neurologic workup in the past was negative with no cord compression and his neurologic symptoms had not changed. The patient was hemodynamically stable and needed no particular new assessment. Thus, inpatient admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.