Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission.

The health plan's determination is upheld.

The patient is a male with a past medical history significant for hypertension, type II diabetes mellitus, hyperlipidemia, history of spinal fusion, and history of amputation of toes on the right foot due to osteomyelitis who presented to the emergency department to obtain medical clearance for surgery. Reportedly, a few weeks before the presentation he was admitted because of a syncopal episode. During this admission, he was found to have osteomyelitis of the distal half of the residual fifth metatarsal, as well as a back abscess that was drained. During the most recent hospitalization a peripherally inserted central catheter (PICC) line was placed, and the patient was discharged home with intravenous antibiotics. He was instructed to come back in two weeks for possible surgery. The patient was admitted with a diagnosis of osteomyelitis of the remnant of the right fifth toe. The admitting physician decided to continue treatment with intravenous Daptomycin that was initiated before this admission. In the hospital, the patient was seen by a podiatrist. It was recommended to continue treatment with intravenous antibiotics, local wound care. It was documented that the surgery was booked. Reportedly, infectious disease service was also consulted, however, before they came to see him, the patient signed out against medical advice. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient at the acute inpatient level of care. This patient presented to the hospital with a known history of osteomyelitis to obtain medical clearance for the upcoming surgery. It was clearly documented that the patient already had a PICC line and was receiving treatment with intravenous antibiotics.
During the entire hospital stay, the patient was afebrile and hemodynamically stable. He had a normal white blood cell count. There was no evidence that the patient's pain was so severe that it necessitated acute inpatient management. There was no evidence that the patient had limb-threatening infection or failure of outpatient treatment. The patient was already scheduled for a surgical procedure, and overall remained in stable clinical condition.
Taking into consideration these facts, there is no evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care.
Considering the fact that the patient's kidney function was off the baseline, the admission for monitoring and administration of intravenous fluids was reasonable. However, this evaluation and treatment did not necessitate admission at the acute inpatient level of care and could have been accomplished at a lower level of care status.
This determination is consistent with Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition Criteria for Osteomyelitis. The review of the medical records did not show evidence that in this clinical case the patient, met the criteria.