Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis (right knee)
Treatment: Room and board (private medical/surgical)
The insurer denied Room and board (private medical/surgical).
The denial is upheld.

This is an adult male with right knee pain. He underwent a right total knee replacement. He previously underwent a left total knee replacement nine months ago. He reportedly had continued pain after his operation that required intravenous (IV) narcotics. The 
patient was discharged on day 7. There was no reported past medical history for problems.

The requested health service was not medically necessary.

The medical records show a non-complicated post-surgical course in a male with no significant underlying medical history. His surgery was performed in a satisfactory manner. It was of limited duration with minor blood loss. The patient's vital signs were stable. There was no evidence of bleeding. He did not have problems with his wound nor infection. He was able to tolerate his pain mediation regimen. The patient made satisfactory gains with physical therapy/occupational therapy (PT/OT). There were no reports of "severe pain" to require the additional length and acuity of service. Therefore, the requested health service was not medically necessary.
According to the Milliman Care Guidelines (MCG Pain Management GRG), inpatient admission is indicated by any one of the following: 
- Severe pain requiring acute inpatient management as indicated by one or more of the following:
 - Continuous or frequent (e.g. [for example], every two to four hours) parenteral analgesics required; 
 - Necessity (i.e. [that is] alternative approaches not effective) for analgesic regimen that can only be performed or initiated in inpatient setting [NOT MET]
- Severe side effects from pain medications as indicated by one or more of the following: [NOT MET]
Uncontrollable seizures [NOT MET]
Cardiac arrhythmias of immediate concern [NOT MET]
Dehydration that is severe or persistent [NOT MET]
Vomiting that is severe or persistent [NOT MET]
Altered mental status that is severe or persistent GCS (Glasgow Coma Scale) Calculator [NOT MET]
Constipation with inadequate gastrointestinal function to maintain nutrition [NOT MET]
Pain causing debilitation to the point that patient is unable to function or be supported at any other level of care [NOT MET]
AND
Extended stay beyond goal length of stay may be needed for:
- Deep venous thrombosis or pulmonary embolism [NOT MET]
- Anticipate anticoagulation as indicated and local external measures. See Venous Thrombosis and Pulmonary Embolism: Common Complications and Conditions ISC (intermittent sequential pneumatic leg compression) for further information. [NOT MET]
- Expect brief to moderate stay extension [NOT MET]
- Surgical complications (e.g., injury to popliteal artery, peroneal nerve) [NOT MET]
- Complications may require acute inpatient care or reoperation [NOT MET]
Expect brief to moderate stay extension [NOT MET]
Acute arterial thrombosis [NOT MET]
Anticipate thrombectomy and possible bypass [NOT MET]
Expect brief to moderate stay extension. 
Extensor mechanism rupture [NOT MET]
Extensor mechanism rupture requires surgical repair [NOT MET]
Expect moderate stay extension.
Infected knee joint or operative site [NOT MET]
Anticipate antibiotics, cultures, and monitoring of hemodynamic stability [NOT MET]
Expect brief to moderate stay extension.
Fat embolism [NOT MET]
Anticipate hemodynamic and ventilatory support and possible steroids.
Expect moderate to prolonged stay extension. 
Periprosthetic fractures [NOT MET]
Periprosthetic fractures may require protected weight-bearing, cast or brace immobilization, surgical fixation, or revision arthroplasty.
Expect brief to moderate stay extension.
None of the conditions were present to require the length of stay nor level of service.