Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Leg pain bilateral.
Treatment: Inpatient Hospital Stay.
The health plan denied the inpatient hospital stay as now medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient is a female with a past medical history significant for schizophrenia, type II diabetes mellitus, pulmonary embolism, hypertension, hyperlipidemia, seizures, coronary artery disease, and cerebrovascular accident (CVA) with residual right-sided weakness who presented to the hospital for evaluation of bilateral leg pain and swelling. The patient stated that she had lower extremity pain and swelling when her roommate "did witchcraft" on her.  In addition, the patient reported dyspnea on exertion and orthopnea. The patient also noted multiple episodes of nonbloody non-bilious vomiting.
The patient denied chest pain, shortness of breath, abdominal pain, diarrhea, constipation, suicidal ideations, homicidal ideations, and visual or auditory hallucinations. The patient underwent a bilateral lower extremity venous duplex ultrasound, which demonstrated no evidence of deep vein thrombosis (DVT).
The patient was admitted to the hospital with a diagnosis of dyspnea on exertion, bilateral leg pain, schizophrenia, and other chronic medical problems. In the hospital, the patient was seen by a neurologist who recommended continuation of treatment with gabapentin, utilizing a Lidocaine patch and muscle relaxants, as well as physical and occupational therapy evaluation.
The patient was seen by a pulmonologist who stated that the patient had no previously diagnosed pulmonary conditions but was complaining of some shortness of breath. It was recommended to obtain a venous blood gas (VBG). The pulmonologist stated that the chest x-ray looked clear. There was low suspicion for pulmonary embolism since the patient's D-dimer was normal.
A nephrologist saw the patient due to chronic kidney disease. According to the nephrologist, the patient's kidney function was at the baseline. The patient was seen by a neurologist who stated that the leg weakness was going on for at least 2 years. It was also mentioned that the patient previously underwent extensive evaluation for this. The neurologist recommended treatment with Gabapentin and muscle relaxants. The patient was evaluated by a cardiologist who indicated in the consultation note that the patient came with dyspnea on exertion, but her lungs were clear to auscultation. The patient had normal pro brain natriuretic peptide (proBNP) and D-dimer levels, and the symptoms resolved. During the hospitalization, a psychiatrist also saw the patient. Per psychiatry, there was no need for inpatient hospitalization. It was recommended to continue a home regimen of psychiatric medications. Since the patient's clinical condition improved, she was discharged from the hospital.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with complaints of lower extremity pain, which was chronic. The lower extremity swelling, which was one of the presenting symptoms, was mild and was not associated with congestive heart failure (CHF) exacerbation or DVT. The patient's hallucinations were chronic and related to her underlying psychiatric conditions. It was clearly indicated that she did not have suicidal or homicidal ideations. The patient did not need inpatient psychiatric treatment for her symptoms. The results of the physical exam were generally reassuring, as well as the laboratory studies results. The patient did not need any diagnostic studies or interventions necessitating admission at the acute inpatient level of care.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was within the scope of a lower level of care.