Diagnosis: Right Foot Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male who presented to the hospital with complaints of right foot pain after falling off the table 3 days before this presentation. The patient was painting a ceiling and, upon falling, twisted his right ankle and developed swelling and bruising. He was unable to walk secondary to pain. Vital signs on arrival include tachycardia of 153, with a blood pressure of 156/97 and normal temperature. The patient expressed nervousness whenever he sees a physician. There were no reports of chest pain, shortness of breath, nausea, or vomiting.

The patient was admitted for sinus tachycardia. Cardiac troponins were negative. The secondary documented problem is blood glucose of 238; the medical team ordered glycated hemoglobin (A1c) and lipid panel. The next day, the patient was reassessed and noted no tachycardia while sleeping but a heart rate of 130 with exertion. The medical team noted iron deficiency anemia, ordered an echocardiogram, and started iron supplementation. The echocardiogram (ECG/EKG) revealed a preserved ejection fraction with no regional wall motion abnormalities. As a result, the patient was released from the hospital.

The subject under review is the medical necessity for an inpatient admission. The health plan's determination is upheld in whole.

An inpatient admission was not medically necessary for this patient. The patient came into the hospital for ankle pain, and the fracture was ruled out. The rest of the workup does not require an inpatient level of care. The patient was hemodynamically stable, had no ST segment changes on EKG, and had no cardiac arrhythmia such as supraventricular tachycardia (SVT) or atrial fibrillation. The EKG showed sinus tachycardia, which was probably a combination of pain and nervousness at the hospital, as documented in the notes, and no clinical concerns for decompensated heart failure. There is no clinical reason to perform cardiac workup in the hospital setting. Laboratory studies are all unremarkable. Pulmonary embolism was ruled out in the ED (emergency department). An inpatient admission exceeds the needs of the clinical presentation. The patient could have been managed at a lower level of care status.