Diagnosis: Uncontrolled pain

Treatment: Inpatient admission, medication, monitoring

The insurer denied the inpatient admission. The denial was upheld.

This is a male with a past medical history of diabetes type 2, psoriasis, Lyme disease, Methicillin-resistant Staphylococcus aureus (MRSA) in the bilateral lower extremities, bilateral below-the-knee amputation (BKA), kidney stones and deep vein thrombosis. The patient was brought to the emergency department with "pain all over," high blood sugar, left phantom leg pain and a 10-second syncopal episode. His current pain level was 10/10. The patient's blood pressure was 139/94 and his heart rate was 110. He had psoriasis covering most of his body and stated that it was painful. He reported that he had run out of his insulin. The patient reported intermittent chest pain with pain down his right arm. Laboratory studies revealed leukocytosis, negative troponin level and glucose level of 350 on arrival. He was given 20 units of regular insulin. Cardiovascular exam was normal. He was noted to be stable. Given the patient's current social situation and uncontrollable pain, he was admitted to medicine observation.

The Milliman Care Guidelines indicates a hospital admission for pain management may be appropriate for patients with severe pain requiring acute inpatient management, including the need for intravenous opiate administration, as indicated by pain that is unresponsive to non-opioid analgesia and non-pharmacologic treatment, when oral, transdermal, or submucosal route would not be appropriate or insufficient, when anticipated hydration is not appropriate for a lower level of care, or when pain control regimen for the next level of care is not established, as sufficient pain control cannot be achieved. The patient had been given Percocet followed by Flexeril for pain, which improved his symptoms. The records failed to support the patient had a necessity for intravenous opiate titration or had a pain control regimen for the next level of care that was not established, as it was documented sufficient pain control had been achieved. The records failed to support that the patient's condition did not improve after the oral medications. The records failed to support the necessity for a full admission.

Based on the above, the medical necessity for the inpatient services is not substantiated. The insurer's denial is upheld.