Diagnosis: Orthopedic/Musculoskeletal-Knee problem/pain
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

This is a case of an obese male patient admitted to the hospitalFebruary for a diagnosis of acute onset left knee pain. The patient presented with chief complaint of acute onset left knee pain in the setting of trauma. Vital signs showed blood-pressure 127/77, pulse 79, temperature 98.1°F, respiratory rate 22 and oxygen (O2) saturation 97% on room air. Physical exam showed lateral right foot tenderness to palpation and left knee without erythema, lesions, or deformities. X-ray of the right ankle showed no fracture or dislocation. X-ray of the right foot showed no fracture or dislocation. X-ray of the left knee showed an irregularity of the tibial plateau and posterior tibia with large suprapatellar joint effusion. Orthopedic surgery consult was requested. Orthopedic surgery and musculoskeletal radiology reviewed the computed tomography (CT) imaging of the knee and it was determined that there was no injury to bone, tendon, or ligament. The patient was recommended to be treated with a hinged knee brace and was scheduled to have outpatient follow-up with orthopedic surgery.

Medical necessity of an acute inpatient admission has not been established.
According to Up-to-date, 2019:
"Trauma - Trauma sufficient to cause joint pain and swelling is typically recollected by the patient. However, if a loss of consciousness (e.g., due to a drug overdose, motor vehicle accident, alcohol ingestion, or concussion) has occurred, the patient may not remember injuring the joint. Thus, if there is a history of joint injury or loss of consciousness, initial immobilization, and imaging studies to rule out a fracture or dislocation are appropriately obtained before proceeding with a thorough physical examination of the joint.
Intraarticular fractures, dislocations, ligamentous sprains, and complete tears (e.g., of the anterior or posterior cruciate ligaments of the knee), and meniscal damage are often associated with hemarthrosis. Intraarticular bleeding may also be related to coagulopathies, anticoagulation therapy, intraarticular tumors, and crystal disease, among other causes. (See "Overview of hemarthrosis".)"
The patient in this case did not have loss of consciousness, fracture, dislocation, or ligamentous sprain. There was no complete ligament tear or meniscal damage. There was no hemarthrosis, intra-articular bleeding, coagulopathy, anticoagulation therapy, intraarticular tumor, or active crystal disease.
Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, medical necessity of admission has not been established.