Diagnosis: right knee pain

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is upheld.

This female patient has no significant past medical history.

The facts were the patient did not demonstrate findings which would support that diagnosis. ie. The patient was afebrile and vital signs were stable. Laboratory studies were normal. It would not be likely to have normal values in the presence of osteomyelitis. Nevertheless, the aspiration did not show evidence of bacteria. The cultures were negative. The child was reported to be comfortable taking Advil watching movies.

These findings do not substantiate necessity of an admission to rule out osteomyelitis. The services provided could have been obtained in a physician office. ie. Aspiration with orthopedic consultation. An orthopedic oncological evaluation could have been made as well.
There were no extenuating circumstances to warrant the level of service. It could have been completed at a lower level.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for inpatient hospital admission is upheld. The medical necessity is not substantiated.