Diagnosis: End-stage renal disease on hemodialysis, cirrhosis, gout, diabetes, and hypertension.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with end-stage renal disease on hemodialysis, cirrhosis, gout, diabetes, and hypertension. He was admitted with right knee pain and swelling. The patient had recently been treated with a corticosteroid taper for a gout flare. The patient was afebrile with the blood pressure 137/74 and pulse 76. The examination demonstrated bilateral lower extremity edema with tenderness to palpation around the right knee. Labs were notable for white blood cell count 6.7, hemoglobin 9.2, brain natriuretic peptide 7200, uric acid 10.3, potassium 4.9, and bicarbonate 28. The chest x-ray demonstrated pulmonary vascular congestion. Lower extremity Dopplers demonstrated a cystic mass in the right popliteal fossa and no deep venous thrombosis. Hemodialysis was performed with ultrafiltration. Knee arthrocentesis was performed with an intra-articular corticosteroid injection. Oral steroids were provided.

No, the proposed Inpatient Hospital Admission is not medically necessary.
The patient's knee pain was due to a gout flare and was not accompanied by inability to ambulate or severe pain requiring frequent intravenous analgesics. The patient did not require intravenous corticosteroid therapy. There was no evidence of septic joint or musculoskeletal injury. The patient remained hemodynamically stable and afebrile. There was no evidence of fracture. Laboratory indices were compensated. Although the brain natriuretic peptide was elevated, there was no evidence of acute heart failure or pulmonary edema. In summary, inpatient admission was not medically necessary.