Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Hip Pain
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Upheld

The patient is a male who presented to the emergency department with concerns for right hip pain. Pertinent history included hypertension, obstructive sleep apnea, and right shoulder arthroscopy. Initial vital signs revealed a temperature of 98.1 Fahrenheit (F), heart rate (HR) 74, blood pressure (BP) 143/93, respiratory rate (RR) 17, peripheral capillary oxygen saturation (SpO2) 97% on room air. Initial examination documented the patient with the ability to stand on legs with pain to right hip. Initial laboratory testing revealed a white blood cell (WBC) 9.4, erythrocyte sedimentation rate (ESR) 17, C-reactive protein (CRP) 82.10. X-ray of the right (R) hip revealed no evidence of fracture or dislocation. Duplex ultrasound was negative for deep vein thrombosis. magnetic resonance imaging (MRI) of the right hip revealed marked edema and surrounding fluid of right gluteus medius muscle suspicious for a high-grade tear as well as findings suggestive of trochanteric bursitis. Orthopedic surgery consulted in the emergency department and documented low suspicion for infectious bursitis, but rather a reactive process secondary to gluteus medius rupture. No antibiotics or intervention recommended. The patient was admitted thereafter. Treatment plan included supportive medication and infectious disease consultation. The patient remained afebrile and hemodynamically stable. Pain was controlled on current regimen. WBC count was 7.2. Physical therapy evaluated and recommended outpatient therapy. Infectious disease consulted and documented no signs or symptoms of infection. No antibiotics were recommended. There were no new issues. The patient was ambulatory, there was no significant change in plan. Rheumatology consulted and recommended supportive management with heat and stretching. The patient was discharged thereafter.
The subject under review is the medical necessity for a full hospital admission.

The health plan's determination is upheld.

The full hospital admission was not medically necessary for this patient.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient presented with right hip pain and was diagnosed with a gluteus medius tear with possible trochanteric bursitis. A comprehensive evaluation was performed and essentially unremarkable with the exception of an elevated CRP and MRI findings of the aforementioned tear. Orthopedic surgery consulted in the emergency department and ruled out an infectious process. No intervention recommended. Infectious disease consulted and did not recommend antibiotic therapy. Treatment plan was essentially non-steroidal anti-inflammatory drugs (NSAIDs), heat, and therapy. Following observation, symptoms were controlled, and the patient was ambulatory. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have a newly diagnosed or suspected bone, joint, muscle, or orthopedic device infection that required intravenous (IV) antibiotics, device removal, joint drainage, or debridement. The patient also did not have a fracture, dislocation, or musculoskeletal injury requiring inpatient care. Lastly, the patient did not have a severe rheumatologic disease, severe crystal arthropathy, rhabdomyolysis, or severe myopathy.[2]