Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Pressure Ulcers
Treatment: Inpatient Hospital Stay

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient is a female with a history of bilateral lymphedema, congestive heart failure, obstructive sleep apnea, hypertension, and diabetes mellitus who initially presented with concerns of ambulatory dysfunction and pressure ulcers. The emergency department physician documented wound care and placement as reasons for hospitalization. The admitting physician documented an impression of self-care deficit for dressing and grooming. The treatment plan included home medications, therapy services, and pain management consultation. In addition, the admitting physician documented the patient was expected to be medically discharge ready after therapy services evaluation. Physical Medicine and Rehabilitation (PM&R) consulted and recommended skin care, as well as subacute rehabilitation when deemed medically stable. Over the next week, no new issues or complications of significance were documented. Therapy services, wound care, and analgesic adjustments were continued. The patient was documented as tolerating physical therapy with improved pain control. However, a catastrophic sequence of events was documented and the patient expired. At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence based literature and standard of care, acute inpatient level of care was not medically necessary.
The patient had a history of bilateral lower extremity lymphedema, pressure ulcers, and morbid obesity who initially presented with ambulatory dysfunction and painful pressure ulcers after being discharged home from a nursing facility. Initial examination documented the patient as alert, oriented, afebrile, hemodynamically stable, without hypoxia, and with pressure ulcers involving the buttocks and groin. Initial evaluation revealed relatively unremarkable laboratory testing. The emergency department physician documented wound care and placement as reasons for hospitalization. The admitting physician had a similar impression and documented the patient would be medically cleared for discharge following physical therapy services evaluation. Treatment thereafter included topical wound care, oral medications, and therapy services. This plan remained relatively unchanged for the next eight days of the hospital stay with documentation noting clinical improvement of presenting concerns. On hospital day number (#) 10, a catastrophic sequence of events occurred with the patient ultimately expiring. The day preceding the events, documentation noted stability without any indication of impending organ failure or other urgent clinical concerns.
Clinical indications for admission to inpatient care were not met. The patient did not require pressure injury closure or other procedure needed due to failure of conservative management. The patient did not have a skin disease or infection requiring inpatient care, such as severe pemphigus, Stevens-Johnson syndrome, toxic epidermal necrolysis, or disseminated Herpes zoster. The patient also did not have superimposed infections, debridement need, or critical ischemia.[2]