Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Other/Right Foot Pain.
Treatment: Inpatient Hospital Services.
The health plan denied the requested inpatient hospital services as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with history of diabetes, atrial-fibrillation, hypertension, peripheral artery disease status post vascular bypass, and status post a recent amputation of his right foot toes. He left rehab against medical advice (AMA) He was then admitted to a subacute rehab (SAR) and left there AMA, but returned to the emergency department (ED) for evaluation of right foot pain and a request for admission to rehabilitation. After leaving AMA, he noted foot pain and difficulty walking. He wanted to go back to a rehabilitation facility. On exam, his right foot wound looked clean and was without discharge. His ED vitals were a temperature of 98.7F., a heart rate of 73 beats per minute, a blood pressure of 118/84 millimeters of mercury, a respiratory rate of 19/minute, and a peripheral capillary oxygen saturation of 98%. His labs showed a white blood cell count (WBC) of 11, a hemoglobin of 11.9, a sodium of 137, and a creatinine of 0.98. His erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were noted to be down-trending. He was given Oxycodone for pain in the ED. The patient was ordered admission for subacute rehabilitation placement. There was low suspicion for infection. His plan of care was a physical therapy (PT) evaluation, pain control, bowel regimen, wound care, continue home medications (e.g. Eliquis, Toprol, Lipitor). His x-ray was negative for gas or acute fracture. Podiatry was consulted; they saw the patient and also had a low suspicion for infection. They had wound dressing recommendations. They also recommended he be continued on the oral antibiotics he was supposed to be on from his prior discharge. He was started on oral Cephalexin. His WBC improved to 7.21 and he was awaiting rehab placement based on PT recommendations. He denied foot pain. Later, the patient elected to leave the hospital, as he was apparently not given authorization for subacute rehabilitation. At issue is the medical necessity for the inpatient hospital services.

I uphold, in whole, the health plan's determination of medical necessity.

No, hospital services were not medically necessary for this patient at the inpatient level of care. 
He required a hospital admission; however, he could have been safely admitted and treated at an alternate level of care, rather than an inpatient level of care. The facts in the record failed to indicate risk or severity that would require a protracted hospitalization. The patient did not appear to have had any acute medical needs that would require inpatient level of care. His foot pain was not intractable and did not require intravenous (IV) analgesics for treatment. He was adequately treated with oral Tylenol and Oxycodone. He was not septic (i.e. he did not meet sepsis criteria, whether by systemic inflammatory response syndrome (SIRS) or (qSOFA) sequential organ failure assessment criteria and did not require IV antibiotics. It appears he was started on an oral antibiotic simply to continue his antibiotic regimen from his prior hospitalization. The patient was afebrile and hemodynamically stable throughout the admission. His wound was not thought to be actively infected by the primary team or by the podiatrist. His inflammatory markers (ESR and CRP) were actually noted to be down-trending, indicating an improvement in the inflammatory process. He had no drainage from the wound that might indicate infection. Workup during his recent admission was negative for osteomyelitis and there was no suspicion for it on this admission. His primary indication for hospitalization was therefore for placement to a subacute rehab, which makes it a custodial admission. His hospitalization crossed 48 hours, however, he had no acute medical needs that warranted inpatient level of care. An alternate level of care would have been adequate for this patient.