Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Elbow Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient came to the emergency department with complaints of right elbow pain that started several days before the presentation. The patient noticed redness and swelling in the right elbow that progressively became worse. At the time of the initial evaluation, he denied a fall, injury, bug bites. He reported a fever, chills, and fatigue. He denied weakness or numbness to the right upper extremity.
Upon presentation, his temperature was 38 degrees Celsius (C), heart rate 77 beats per minute (bpm), respiratory rate 18 breaths/minute, blood pressure 128/88, and oxygen saturation 97% on room air. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound.
There was erythema, tenderness, and swelling in the right elbow with redness extending up to the distal humerus and proximal radius/ulna area. There was a boggy fluctuant mass adjacent to the right olecranon. There was a full range of motion in the joint, although it was painful and warm. The rest of the physical exam was unremarkable.
The patient was admitted to the hospital with a diagnosis of right elbow cellulitis versus olecranon bursitis.
Laboratory evaluation revealed that the white blood cell count was 14.4, hemoglobin 15.4, and platelets 163. The sodium was 138, potassium 4.6, blood urea nitrogen (BUN) 10, creatinine 0.7, and glucose 77. The C-reactive protein (CRP) was 137.
An x-ray of the right elbow showed no fracture or dislocation. There was a suggestion of soft tissue swelling. In the hospital, the patient received treatment with intravenous fluids and intravenous antibiotics.
During the hospital stay, the patient was seen by orthopedic surgery. It was determined that the patient had olecranon bursitis with superimposed cellulitis. Based on the evaluation by an orthopedic surgeon, there were no indications for joint aspiration or corticosteroid injection. Before the discharge, the patient was transitioned to oral antibiotics and discharged home.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
This patient was a generally healthy individual who most likely had olecranon bursitis with secondary cellulitis. Considering that sepsis syndrome was suspected at the time of the initial evaluation, it was necessary to rule out sepsis as well as determine the correct diagnosis, however, this could have been done at a lower level of care.
The patient did not meet the sepsis criteria. Furthermore, his clinical condition improved quickly. He did not have clinical features that would make his clinical condition more serious.
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.