Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip Pain, Arthritis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who was scheduled to undergo elective right total hip arthroplasty. The patient is noted to have chronic right hip pain and degenerative arthritis. The patient has been treated conservatively with non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and topical cream that was initially effective, but the patient is now in almost constant pain. The patient has difficulty with activities of daily living. The physical examination of the right hip reveals tenderness in the greater trochanter and anterior regions. The provider reports that x-rays of the pelvis, right hip, and lumbar spine show right hip severe degenerative arthritis with bone-on-bone configuration, spurring, and subchondral cysts, and lumbar spine spondylosis facet joint hypertrophy most prevalent at lumbar (L) 4-L5 and L5-sacral (S) 1, and mild scoliosis.
A physical medicine and rehabilitation consultation report indicates the patient is being evaluated to determine functional deficit, rehabilitation need, and restorative potential. The physical examination of the right lower extremity reveals an intact dressing, intact sensation, intact dorsalis pedis pulse, and tenderness. It is noted that the patient has impaired mobility and activity of daily living/ambulation impairments with a recommendation for continuation of physical therapy while in the hospital. There is a recommendation for subacute rehabilitation upon discharge from the hospital.
A physical therapy initial evaluation report indicates the patient has decreased functional mobility requiring assistance of others in areas of bed mobility, transfers, and ambulation, and the patient could benefit from inpatient skill therapy intervention. The provider indicates the patient could benefit from subacute rehabilitation. A physical medicine and rehabilitation progress note recommends continuation of the current plan of care. It is noted the patient was seen and examined at the bedside, and the patient is lying comfortably in bed.
A physical therapy progress note indicates the patient has decreased functional mobility requiring assistance of others in areas of bed mobility, transfers, and ambulation, and the patient could benefit from inpatient skill therapy intervention. The provider indicates the patient could benefit from subacute rehabilitation.
At issue is the medical necessity of an inpatient stay.
 
The submitted documentation indicates the patient underwent scheduled elective right total hip replacement for the treatment of right hip degenerative joint disease. There were no intraoperative or postoperative complications. Comorbidities did not require any acute care. The patient was able to tolerate physical therapy and was noted to have well-controlled pain. There is no documented need for intravenous pain medications. There were no factors requiring an inpatient level of care. The records indicate the patient could have been safely and effectively treated at a lower level of care in the hospital followed by discharge to a subacute rehabilitation facility. Based on the submitted records, inpatient hospital admission was not medically necessary for this patient.