Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Pain (skin infection )
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male. He has a past medical history of hypertension (HTN), hepatitis C, peripheral vascular disease, implantable cardioverter-defibrillator (ICD), and alcohol abuse.  He presented with complaint of bilateral leg pain.

On admission exam, the patient was afebrile and hemodynamically stable. His vital signs on presentation were T (temperature) 98.3, BP (blood pressure) 160/84, P (pulse) 93, R (respiration rate) 18, and pulse oximetry - 97 (percent) %. The patient was admitted to hospital for further management.

The patient's physical examination reported bilateral lower extremities with open wounds and no local neurological deficits. Laboratory values reported the alcohol level 177, white blood cell count (WBC) 6.1 and glucose 145. Imaging studies reported no evidence of deep venous thrombus (DVT). The patient was treated with pain medications, CIWA (clinical institute withdrawal assessment) protocol (score was 0), home medications, antibiotics, wound care, supportive care, and medication optimization. General surgery recommended no acute intervention. The patient was discharged.

No, the Inpatient admission was not medically necessary.
There was no evidence of the patient being immunocompromised, hemodynamic instability, infection located over a prosthesis or implanted device or orbital cellulitis.

Inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk as based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition.

For the duration, the patient was afebrile and had stable vital signs. The patient did not have symptoms that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered/work up initiated, and there was no change in management plans that would justify/necessitate inpatient stay in the hospital.

During the above duration, the patient's diagnosis had been established clinically and based on the results of the investigations. The patient was hemodynamically stable and afebrile. For the above duration, the patient had stable vital signs, and routine labs remained at baseline. The patient's temperature and other vital signs were not representative of sepsis during this time. General and systemic examination was normal or at baseline.  Care rendered during this time was of low intensity, routine nursing and physician monitoring. No systemic findings such as high fever, shock, renal or liver failure or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. The patient was not in acute distress. In view of these facts of the patient's clinical status, ongoing risk of deterioration was low, since diagnosis had been established and patient was responding appropriately to the treatment. The patient did not have any acute complications during this time. No high frequency, high complexity, or high risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time.

In view of these findings and generally in accordance with MCG (Milliman Care Guidelines) guidelines therefore, the inpatient level of care for the above duration was not medically necessary.

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