Appeal type: Medical necessity
Decision: Upheld

This patient, with a past medical history significant for hypertension and deep vein thrombosis, was admitted to the hospital under podiatry service, after a left foot arthrodesis on the day of admission.
Reportedly, the patient had pain in the left foot that became worse over time. The patient tried different types of conservative treatment, but the pain was not controlled, therefore the surgical intervention was performed.
After the surgery, the patient was admitted to the hospital and the internal medicine service was consulted for medical management. When the patient was seen by the internal medicine doctor, that patient was afebrile, with pulse rate of 54 beats per minute, a respiratory rate of 18, a blood pressure of 131/88, and an oxygen saturation of 98% on room air. The patient appeared to be in no acute distress, and reported a pain level at that time as 0/10. The patient had no peripheral edema or erythema. The neck was supple, and no jugular vein distention (JVD) was noted.
The pulmonary exam was unremarkable. The cardiac exam was within normal limits. The abdominal exam was benign. The patient had a left lower extremity in a cast. The rest of the physical exam was unremarkable.
The internal medicine doctor indicated in the consultation note that the patient had a history of provoked deep vein thrombosis (DVT) approximately 10 years before the day of admission. The most recent venous duplex ultrasound was negative for a DVT. The internal medicine physician recommended prophylaxis with Lovenox for 14 days. Another clinical problem was hypertension, which was well-controlled on the patient's home regimen.
Reportedly, during the hospital stay the patient spiked a fever. It was associated with chills and headaches. The symptoms were transient and resolved after the administration of Tylenol and did not recur. On that day, the patient was seen by an internal medicine physician again, who indicated that the patient denied shortness of breath, chest pain, headache, palpitations, any skin lesions, or urinary symptoms. Her level of pain on that day was documented as 0/10. The review of systems was negative for everything except for constipation. A chest x-ray, urinalysis, and urine culture were obtained but remained unrevealing. Subsequently, the patient was discharged from the hospital in satisfactory clinical condition.
At issue is the medical necessity of the inpatient admission. 

The health plan's determination is upheld in whole. The requested health service/treatment of inpatient stay was not medically necessary for this patient at the acute inpatient level of care.
This patient underwent left foot arthrodesis on the day of admission, which is an ambulatory procedure. The patient's postoperative stay was unremarkable except for an isolated episode of fever, which responded quickly to treatment with Tylenol and never recurred. The workup performed for the evaluation of the fever did not reveal any significant abnormalities.
The patient's postoperative pain was very well controlled and did not require prolonged administration of parenteral pain medications. The patient was able to tolerate a diet and oral medications.
Even though the patient had a remote history of deep vein thrombosis, there was no evidence that the patient developed an acute DVT after the surgery. Routine DVT prophylaxis was received following the surgery. Reportedly, the patient underwent a venous duplex ultrasound for an evaluation of pain in the lower extremity, which came back negative for an acute DVT.
The review of the medical records demonstrated that the patient did not have any medical conditions during this period of time following the surgery that would require admission at the acute inpatient level of care. If the podiatry service had a concern about pain control and the possibility of a DVT, the patient could have been admitted at a lower level of care to ensure adequate pain control and to rule out a DVT.