Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteomyelitis
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is upheld. 

The patient at time of presentation was a male with a past medical history significant for attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and heroin abuse who presented to the hospital due to vertebral osteomyelitis. He was admitted to the hospital previously but left against medical advice on several occasions. It was reported that while in the hospital, he received treatment with intravenous antibiotics including vancomycin and cefepime, but he was unable to be discharged with intravenous antibiotics due to his history of heroin abuse. The admitting physician stated that in the emergency department the patient was afebrile and had stable vital signs.
At the time of admission, the patient's temperature was 97.7F, blood pressure was 131/66, heart rate was 106, and oxygen saturation was 97% on room air. The patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. There was a normal range of motion in all extremities with no clubbing, cyanosis, or edema. The neurologic exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 6.9, hemoglobin was 11.3, hematocrit was 33.9, and platelets were 331. Sodium was 140, potassium was 4.2, chloride was 102, bicarbonate was 28, blood urea nitrogen (BUN) was 11, creatinine was 0.85, and glucose was 93. Liver function tests were normal. Urinalysis was unremarkable.
The patient was admitted to the hospital with a diagnosis of back pain and osteomyelitis of the lumbar vertebra, as well as other chronic medical problems. During the hospital stay, it was determined that the patient was drug-free, therefore the decision was made to place a peripherally inserted central catheter (PICC) line with locks. Subsequently, the patient was transitioned from Cefepime to ertapenem in preparation for discharge. The patient also remained on Zyvox for methicillin-resistant staphylococcus aureus (MRSA) coverage. At the end of the hospitalization, the patient was discharged home.
At issue is the medical necessity of Inpatient Admission.

The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Inpatient Admission is not medically necessary for this patient.
This patient was admitted to the hospital with an already established diagnosis of vertebral osteomyelitis and discitis. The patient had already been treated with the same intravenous antibiotics in the past. At the time of admission, he was afebrile and hemodynamically stable. The only thing he required during the hospitalization is the placement of a PICC line and the establishment of a regimen of intravenous antibiotics. He did not need any surgical procedures or interventions that would necessitate admission at the acute inpatient level of care. There was no evidence that the patient's condition was too unstable, which would preclude him from a fast transition from the hospital to the outpatient setting. Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.
Therefore, the requested health service/treatment of Inpatient Admission is not medically necessary.