Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Degenerative Joint Disease.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial was upheld.  

This is a male patient with a history of hypertension, type 2 diabetes mellitus, and diabetic neuropathy.  The patient presented to the Emergency Room (ER) with complaints of back pain radiating to the right thigh.  The patient's recent Magnetic Resonance Imaging (MRI) of the hip revealed right hip osteoarthritis.  The patient took pain medications on an outpatient basis, but pain continued to worsen.  In the ER, the patient had a systolic blood pressure of 220 which improved to 160.  The patient's ER labs were unremarkable.  The patient was given a lidocaine patch, Toradol, Oxycodone, IV morphine, and Flexeril.  There was no relief.  The patient was admitted to the hospital with degenerative joint disease of the right hip.  A MRI of the spine was performed that revealed degenerative changes of the lumbar spine.  Orthopedic services evaluated the patient and determined that no acute intervention was needed.  The patient was able to weight bear as tolerated.  The patient medical management included Tylenol, Ibuprofen, Flexeril, gabapentin and oral prednisone.  Neurology was consulted with recommendations for a physical therapy evaluation.  The patient was found to be orthostatic secondary to decreased oral intake.  The patient's hospital course was complicated by urinary obstruction and acute kidney injury.  The patient's symptoms improved and his creatinine level improved to 0.9 (baseline level).  After a period of medical stability, the patient was discharged in stable condition.  

Based on the review of the medical record, this patient had hip/back pain for several weeks.  The patient had undergone previous imaging, which diagnosed his hip disease.  The patient had several underlying medical conditions, which required treatment.  However, the services provided could have been obtained as an outpatient, i.e., Orthopedic, Neurology, PMD, Urology and Medicine.  The patient's diagnostic studies also could have been completed as an outpatient.  The patient required assistance with several services, but these could have been met at lower level of care.  The patient was ambulatory with use of a walker (walked greater than 150 feet).  The patient's necessity for catheterization likewise did not require inpatient care.  The patient's pain level was managed by oral medications.  The patient's other medical issues such as hyperglycemia and hypertension was uncomplicated and did not warrant acute level of care. 

As per MCG clinical guidelines, a full hospital admission is medically necessary when major surgery is needed right away or there are severe problems.  However, in this case, the medical records do not indicate that the patient had severe problems, like broken bones in the spine, a spinal infection, a major injury, or paralysis.  The patient did not require surgery or other invasive tests.  Although this patient's case was complex and required multiple practitioners, there were no extenuating circumstances which would warrant the admission and length of stay as provided.  The management could have been completed by lower level of care.  Thus, a full hospital admission is not considered medically necessary based on the Milliman Care Guidelines using the guidelines of Back Pain (ORG: M-63) and Musculoskeletal Disease (GRG: MG-MD.)  

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

The carrier's denial of coverage for the full hospital admission should be upheld.  The medical necessity is not substantiated.