Case 95: Managed Care: Insurance Denial Leads to Two Operations and Two Hospitalizations

At age 72, this businessman presented in Emergency Room on the 25th August, 1995 with an ischemic infected left 5th toe. He had been seen by an endocrinologist for his diabetes several years previously and had been easily controlled. He bought HMO insurance for his business and with his employees shifted his care to the HMO and lost contact with his endocrinologist and lost impetus in controlling his diabetes. Other risk factors for vascular disease included many years of chain-cigar-smoking and a modest alcohol intake. His toe problem began with a blister leading him to a podiatrist who prescribed Augmentin, foot soaks and a half-shoe. The ulcer, however, enlarged, developed a foul smelling drainage and became somewhat painful. He also developed nocturnal left calf discomfort. He presented in emergency room with a 3.5-4.0 cm. ulcer over his 5th toe bunion exposing his tendons; his 5th toe was purple. "Standard" outpatient care by his podiatrist had failed.

His sed rate was 105 mm/hr. His first foot x-ray did not show the osteomyelitis which, considering the drainage and exposure of bone and tendon, was almost certain to be present. His cultures grew out Beta-hemolytic streptococci and Morganella Morganii. He was given injections of Vancomycin and gentamicin into the inflamed areas of his lateral foot, provided with intravenous antibiotics to block septic emboli and booted in the Mini-Boot systems.

Shown here two days after discharge from the hospital, his 5th toe is seen to have mummified and the skin is rounded into the "autoamputation site", September 6th, 1995.

A foot x-ray now showed a pathological fracture through an area of osteomyelitis in his 5th metatarsal head along with small vessel calcifications. Vascular tests were done to ascertain if booting was still necessary and if his circulation was satisfactory to allow surgical amputation of his toe. Amplification of the pulse volume wave forms in the mid-foot showed them to be broad and rounded but still present. His left posterior tibial pulse was absent by Doppler testing and his anterior tibial at the ankle was monophasic, low and broad. Photoelectricplethysmographic (PPG) tracings of the toes were flat with the probes held in place by the routine clips and were broad and low in two toes with the probes held lightly in place with scotch tape but still absent in the other three toes. His transcutaneous PO2 reading was "0" in the lateral foot and the PCO2 72 mm Hg. Such values are well established in the literature to signify a failure of healing (see "Vascular Test section in our Medical Literature). Boot therapy was continued.

The mummified material was clipped off in the office and he appeared likely to close his ulcer with time.

Insurance coverage became a problem. Payments for his outpatient care were denied. The reviewer was not familiar with the Circulator Boot or the vascular tests provided. Further, the reviewer claimed that the medical necessity of our tests and treatments was determined solely by the insurance company; the fact that a doctor "may prescribe, order, recommend, or approve a service or supply does not, in itself, make such a service or supply Medically Necessary." Later reviewing physicians for the insurance company pointed out that boot therapy had been begun immediately in the hospital not giving standard care time to fail, that more studies to look for osteomyelitis might have initially been done and that his hospital course of antibiotics was very short (two weeks).

In the interim, he was receiving his Mini-Boot treatments. PPG tracings of the toes were followed. As more formal testing was not to be reimbursed, the presence or absence of PPG toe pulsations with his toes elevated at various levels above the examination table were noted. By December, they were present with the toes elevated three feet above the table. His feet were progressing and a surgical procedure had become an option. With a choice between his pocketbook or that of the insurance company, he consulted his orthopedic surgeon. Additional bone x-rays and bone scans were done. The patient was re-hospitalized and the 5th metatarsal head removed. The skin was primarily closed and he healed. He was now lost both to medical vascular and diabetes follow-up care. A new ulcer developed in December 1996. Again, he had scans and x-ray studies with his orthopedic surgeon. Again he was hospitalized and, on this occasion, had his 4th toe and metatarsal head removed.

Comments: This man is included to illustrate what some consider deceit and dishonesty on the part of the insurance companies. They expect the physician on the scene to evaluate and treat the patient as effectively as possible. Later, with their pocketbook in mind, they may refuse payment for the service. Most clinicians know that when bone is exposed and covered with a discharge, that it is likely infected. Some physicians know that only serial studies will show the extent of the infection because it is the remodeling/healing process that shows the presence of the infection on the x-rays. (If one were to tie a string around a toe and allow it to mummify, for example, its x-ray would remain normal forever as the toe had no blood supply and remodeling was impossible.) On the one hand the insurance company wants physicians to choose carefully among tests and procedures available. Here, failure to order more tests is offered as criticism. Standard care for osteomyelitis, which was clinically obvious, commonly includes weeks of intravenous antibiotics carried out in the hospital and by the visiting nurse at home. Here the insurance company is critical because such costs were not incurred. The insurance company might judge the vascular status of this patient's foot to be normal as one observer (with pulses in her fingertips) recorded the presence of a dorsalis pedis while no one was able to find it with the more sensitive Doppler examination. The course begun on this patient, with the ordering of minimal tests, Mini-Boot and local antibiotics, was successful and economical. Because they refused payment, the patient underwent two additional hospitalizations and batteries of additional tests. In the end, the insurance company has paid far more than they might have had they let him heal his auto-amputation and obtain booting as his PPG's showed necessary. And... new costs are but a matter of time.