Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male child with medical history significant for premature birth at eight months' gestation, intermittent asthma, and obesity. He presented to the ED (emergency department) with nine-day history of leg pain after a fall from a slide, acutely worse over the previous four days. He was seen by his primary care practitioner and prescribe Tylenol. He reported difficulty walking but no fevers or other symptoms. He had cold symptoms several weeks prior to this problem. Lab work completed the day prior to presentation was reportedly unremarkable (CBC [complete blood count], UA [urinalysis]).

The patient's vital signs included temperature 37.2, heart rate 98, respiratory rate 20, and blood pressure 116/73. Examination was significant for mild obesity, no lower extremity edema, spontaneously moving all extremities, no tenderness to palpation of bilateral hips, no erythema or warmth around bilateral hips or knees, tenderness to palpation of the left mid-thigh, no pain with passive range of motion on the left. Laboratory evaluation was unremarkable with WBC (white blood cell] count 10.1K (thousand), CRP (C-reactive protein) 0.8, and ESR (erythrocyte sedimentation rate) 8. X-rays of the pelvis, hip, and knee were negative. He was unwilling to try ambulating, so he was treated with Tylenol. He reported the pain was worsening and he was refusing to even sit up. He maintained the left leg in an externally rotated position. Orthopedics was consulted with recommendations for treatment of presumed transient synovitis, including pain control with NSAIDs (nonsteroidal anti-inflammatory drugs), crutches, and outpatient follow-up.

Ultimately, the patient was treated with ibuprofen, Tylenol, Toradol, and morphine without relief. He was subsequently admitted for further evaluation and management. Admission orders included regular pediatric diet, as well as Tylenol and Motrin for pain. Pain was rated 4/10 at the time of admission and he was able to ambulate with a slight limp. He remained afebrile and did not require any further medications for pain. He was deemed stable for discharge to follow-up with Orthopedic Surgery.

No, the Inpatient admission was not medically necessary.

A number of conditions may result in hip pain, including transient tenosynovitis, septic joint, Legg-Calve-Perthes disease, slipped capital femoral epiphysis, and trauma. It is often difficult to differentiate between these disorder, and may require additional testing (laboratory, radiographic) to make the appropriate diagnosis. Because there is no single test to make the differentiation, a combination of history, physical examination, and diagnostic studies is necessary. Treatment is vastly different between the various diagnoses, as is outcome. Septic arthritis is considered to be an emergency, while transient synovitis is treated only symptomatically.

This male child presented with worsening left lower extremity pain and difficulty ambulating a couple weeks following viral infection and several days after falling from a slide. Laboratory and radiographic evaluation in the ED (emergency department) were unremarkable, but pain management with multiple agents, including Toradol and morphine were not sufficiently effective, with persistent refusal to walk. While it was not unreasonable to monitor him overnight in the hospital for progression or improvement of symptoms, he was overall hemodynamically stable with no evidence of impending sepsis or joint involvement. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care, such as observation.