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 an adult male. He presented to the hospital for right knee pain and swelling as well as redness of the right leg. His past medical history was significant for remote IV (intravenous) drug use. He also had a history of osteomyelitis and hepatitis C. He had been hospitalized a few days prior and thought to have cellulitis. MRI (magnetic resonance imaging) of the knee at that time has demonstrated a meniscus tear and effusion. He was given intravenous antibiotic at that time and discharged on Keflex orally. Initially, the pain improved, but then returned. The patient reported that he can bear weight with mild pain.

There was no swelling of the right knee, but redness was present, along with limitation of movement. Neurovascular was intact in the extremity. There was redness from the knee to the ankle. Vital signs were normal. White cell count was not elevated. Routine labs, including complete blood count and chemistry panel, were normal. The patient appeared comfortable and not in acute distress. He was not toxic appearing. Pain was well-controlled in the emergency room according to nursing documentation.

The patient was given intravenous antibiotics including vancomycin and cefazolin. Orthopedics was called and recommended outpatient follow up. According to the history and physical documentation, septic arthritis was low on the differential. A possible abscess was noted under the patella on point of care ultrasound. Infectious disease was consulted, as was General Surgery. Subsequently no abscess was detected, and no surgical treatment was required. The patient was discharged on oral antibiotics.

The health plan's denial of coverage is based on partly the MCG (Milliman Care Guidelines) criteria and InterQual criteria. Appeal document states that the patient failed outpatient therapy and was not appropriate for intravenous outpatient therapy. Therefore, inpatient hospitalization was necessary. Septic arthritis was suspected.

The Inpatient Hospital Admission was not medically necessary.

Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness that is acute. 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 is based on an assessment of medical factors in the context of known and generally accepted medical knowledge prevalent at the time of determination. 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 outpatient setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition.

In this patient's case the suspicion for septic arthritis was low; vital signs were normal; patient was non-toxic; there was no history of bacteremia; there was no history of immune compromise, and there was no history of uncontrolled diabetes mellitus. General system examination was normal, and the patient was not an active IV (intravenous) drug user. He was on a methadone outpatient treatment plan. Orthopedics was consulted by telephone and recommended outpatient follow up. Although there was initially suspicion for an abscess under the patella; this was not verified later by infectious disease or general surgery. There were no unstable comorbid conditions. Therefore, medical necessity for inpatient hospitalization was not met.