Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Knee Osteoarthritis
Treatment: Full Hospital Admission
The insurer denied the full hospital admission. The health plan's determination is upheld.

The patient is a female with arthritic problems, including rheumatoid disease that is treated with Enbrel. Additional comorbidities include hypertension, lumbar disc disease and stenosis, cervical disc disease, and esophagitis. The provider states that although the patient has significant background arthritic conditions, they appear to be in generally good health. The provider states the patient appears a suitable candidate for surgery.
An operative report indicates the patient underwent left total knee replacement for the treatment of osteoarthritis of left knee. A medicine daily progress report indicates the patient tolerated surgery well, has no significant complaints, and reports on pain but has no nausea. There are recommendations for deep vein thrombosis (DVT) prophylaxis, physical therapy, analgesia, gastrointestinal prophylaxis, bowel regimen, and antiemetics as needed. 

On postoperative day number one, the patient participated in physical therapy and ambulated 30 feet with a rolling walker with contact guard, wavering as tolerated. They had a slow cadence, antalgic step to gait pattern. They continue to be limited by pain, which was rated at 7 out of 10. They required multiple standing rest breaks. There was a mild increase in discharge noted on incisional dressing. The laboratory results include a white blood count of 16.7 and hemoglobin of 11.7. Later, the patient participated in another session of physical therapy and ambulated 25 feet with a rolling walker, weight-bearing as tolerated, with slow cadence and antalgic step to gait pattern. There was some increased surface drainage on the dressing. The patient returned to bed safely. They were seen by the chronic pain service.
On postoperative day number two, the patient participated in physical therapy and ambulated 25 feet three times with a rolling walker, contact guard, weight-bearing as tolerated, with slow cadence and antalgic step to gait. They required seated rest breaks. Stair negotiation was initiated. The patient continued to be limited by pain. She demonstrated buckling with stair negotiation and during ambulation when fatigued. The chronic pain service was consulted. The pain was 10 out of 10 prior to medication and 8 out of 10 after medication. Roxicodone was added to the multimodal pain regimen. A drain was removed. The dressing was changed. The patient participated in another physical therapy session with ambulation for 20 feet with a rolling walker, contact guard, weight-bearing as tolerated. They demonstrated slow cadence and antalgic step to gait. They rated the pain a 5 out of 10. 
On postoperative day number three, there was mild tenderness in the lower abdomen. The patient had not had a bowel movement since the surgery. They continue to receive an aggressive bowel regimen with MiraLAX twice a day and a suppository. An enema was also ordered. The patient then had a bowel movement. There was strikethrough bleeding on the dressing. The dressing was replaced with a clean dressing and new Ace wrap. The patient reported lightheadedness with a blood pressure reading of 90/50. Intravenous fluid Normal Saline was ordered. The patient participated in physical therapy times two. 

On the day of discharge, they participated in physical therapy and ambulated 50 feet and negotiated stairs with handrails and 18 independently. They were placed on continuous passive motion. They were cleared from acute physical therapy. Per neurology, it was likely neuropraxia in the left softness nerve distribution with a
recommendation to continue a steroid taper and continue physical therapy as an outpatient. The patient was medically cleared for discharge home with a referral for skilled home health services.