Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left foot ulcer

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This case involves an elderly patient who presented to the emergency department with a chief complaint of foot pain and a left foot ulcer.  Blood glucose at that time was 226.  The patient had an elevated heart rate of 104 with the remainder of his vital signs relatively stable.  He rated his pain 10/10 located in the left foot, described as aching and occurring intermittently.  The patient had listed diagnoses consistent with peripheral vascular disease, hypertension, and diabetes mellitus.  The patient reported several weeks of a worsening diabetic foot ulcer on the left heel associated with pain.  He was referred to the emergency department by his podiatrist and had been compliant with medications.  On assessment, the patient had a left posterior heel wound measuring 0.5 centimeters (cm) in diameter with eschar, mild swelling, and erythema surrounding the area.  There is tenderness around the ulcer but no drainage.  The left foot was neurovascularly intact with a weak pulse.  The patient's wound was cleaned by a podiatry team, and he denied fever, chills, or claudication.  X-rays of the foot showed no acute bony abnormalities.  Doppler was fairly audible for right posterior tibial and audible right dorsal pedis pulse with faintly audible left dorsalis pedis pulse but not audible left posterior tibial pulse.  The patient was subsequently admitted because of the diabetic foot ulcer for further work-up/care.  The left heel wound measured 2.1 x 1.5 x 0.1 cm with mild erythema noted circumferentially to the ulcer.  There was no proximal streaking noted, but hematoma was noted to the distal medial aspect of the left second digit.  The patient's various conditions were treated while in inpatient status.  This included ketorolac injections, enoxaparin injections, vancomycin, piperacillin, insulin, and blood glucose monitoring.  The patient also received wound care with arterial duplex scan showing significant peripheral arterial disease bilaterally with greater than 50% stenosis of the right superficial femoral artery (SFA) and greater than 70% stenosis of the proximal profunda with occluded right popliteal and posterior tibial (PT), greater than 75% stenosis of the left SFA and proximal profunda femoris and occluded left popliteal artery.  

Vascular planning included angiogram.  The angiography was conducted with findings of left SFA significant segmental stenosis, no patent PT and peroneal, with multiple collaterals.  The dorsalis pedis was not clearly visualized with no PT on foot noticed.  The patient was subsequently discharged later that day prior to receiving any further care and left Against Medical Advice (AMA).  

In the case of this patient, while it was noted that he had a history of peripheral vascular disease and was documented with a left foot ulcer that was causing pain, the patient's treatment could have been rendered on an observational or outpatient basis to include the left lower extremity angiogram.  There were no complications with the procedure and the remaining treatment did not require inpatient care.  The patient's vital signs were relatively stable with no evidence of a significant infection.  The patient's care could have been safely and effectively rendered on a lower level of service and did not require full hospital admission.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.