Diagnosis: Right knee pain.
Treatment: Inpatient admission.

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

This is a female who presented to the emergency department (ED) with a three-day history of right knee pain. She had fallen. Her past history was significant for multiple sclerosis (MS) and requiring wheelchair. She had used ice and Epson salts which did not provide benefit. X-rays were completed demonstrating demineralization and fractures to the tibia and fibula (right and left) metaphysis. A brace was ordered. The patient left against medical advice (AMA).

No, the proposed treatment, inpatient admission, was not medically necessary.

The records show the patient sustained injury to both legs days prior. She was found to have fractures to both legs which would be considered pathologic, ie - demineralized bone. She was non ambulatory with contractures.

Admission would be reasonable if the patient had intractable pain and immediate subspecialty service necessary. The facts were: the diagnosis was established in the emergency department (ED) (plain radiographs), there was no indication of inability to tolerate oral pain medication, and there was no evidence of bleeding, infection nor unstable vital signs.

The patient's treatment consisted of recommendation to apply a brace. The orthopedic and neurology consultation reported no need for acute intervention. Physical therapy services were not necessary as she was not ambulatory. She signed out against medical advice (AMA).

The patient did not require treatment for an underlying medical problem. There was thus no reason why acute inpatient admission was necessary. There were no extenuating circumstances to substantiate the level of service provided.