Diagnosis: Right foot wound.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission. The denial is upheld.

This is a patient with a history of right foot amputation stump with fibro granular wound. He was admitted to the hospital due to right foot wound with hyperglycemia. During admission, urine toxicology was positive for cocaine. Vitals were stable during admission and did not display signs of sepsis, nor did the wound show signs of infection. Patient was non-compliant with diabetes medical management. Patient left hospital against medical advice (AMA).

Based on documentation provided for review the patient was stable. Patient did not display signs of sepsis, and there were negative signs of right foot infection where patient had a history of ulcer in amputation stump area. He demonstrated hyperglycemia and demonstrated non-compliance with controlling diabetes. Patient was stable upon admission.

Wang, X., Yuan, C. X., Xu, B., & Yu, Z. (2022), "Diabetic foot ulceration (DFU) is a devastating complication of diabetes that is associated with infection, amputation, and death, and is affecting increasing numbers of patients with diabetes mellitus. The pathogenesis of foot ulcers is complex, and different factors play major roles in different stages. The refractory nature of foot ulcer is reflected in that even after healing there is still a high recurrence rate and amputation rate, which means that management and nursing plans need to be considered carefully. The importance of establishment of measures for prevention and management of DFU has been emphasized. Therefore, a validated and appropriate DFU classification matching the progression is necessary for clinical diagnosis and management. In the first part of this review, we list several commonly used classification systems and describe their application conditions, scope, strengths, and limitations; in the second part, we briefly introduce the common risk factors for DFU, such as neuropathy, peripheral artery disease, foot deformities, diabetes complications, and obesity. Focusing on the relationship between the risk factors and DFU progression may facilitate prevention and timely management; in the last part, we emphasize the importance of preventive education, characterize several of the most frequently used management approaches, including glycemic control, exercise, offloading, and infection control, and call for taking into account and weighing the quality of life during the formulation of treatment plans. Multidisciplinary intervention and management of diabetic foot ulcers (DFUs) based on the effective and systematic combination of these three components will contribute to the prevention and treatment of DFUs and improve their prognosis."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for hospital admission is not substantiated.