Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Compound mandible fracture (broken jaw)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The case is an appeal request to review the admission for an adult female patient who was admitted after a fall from a bicycle and sustaining facial trauma, a lip laceration and a compound mandible fracture.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The case is an appeal request to review the admission for an adult female patient who was admitted after a fall from a bicycle and sustaining facial trauma, a lip laceration and a compound mandible fracture. The patient had pain, an open compound mandible fracture, broken teeth, and an open lip laceration, in addition to a wrist injury. Her diagnoses and clinical exam indicate and substantiate the medical necessity for the admission. The patient required open reduction and internal fixation of her mandible fracture, along with closure of her lip laceration. This surgery occurred on the evening of her admission. She then was admitted overnight and discharged before noon on the next day . Her pain level postoperatively was 6/10, prior to being medicated adequately to control her pain. 

An admission is required for orthognathic surgery on both jaws and an overnight admission or observation is required to assess the patient for safe discharge to home. Patients must be assessed for and cleared in the following areas prior to discharge: hemostasis, emesis control, airway patency and pulmonary toileting, pain control, adequacy of oral fluid and oral intake, and ability to manage activities of daily living (ADLs). The patient was admitted and managed according to the accepted pot-operative surgical standard of care for patient's recovering from facial trauma surgery, and discharged in an acceptable, timely and appropriate fashion. By denying the admission, the Plan has not acted with sound medical judgment and in the best interest of the patient. The invasive nature of the surgery with respect to its involvement of the airway and potential for swelling and airway compromise, along with the need for overnight narcotic pain medication, warranted acute inpatient admission. The intensity of services was beyond the scope of an observation level of care.

An admission is required for orthognathic surgery on both jaws and an overnight admission or observation is required to assess the patient for safe discharge to home. Patients must be assessed for and cleared in the following areas prior to discharge: hemostasis, emesis control, airway patency and pulmonary toileting, pain control, adequacy of oral fluid and oral intake, and ability to manage activities of daily living (ADLs). The patient was admitted and managed according to the accepted pot-operative surgical standard of care for patient's recovering from facial trauma surgery, and discharged in an acceptable, timely and appropriate fashion. By denying the admission, the Plan has not acted with sound medical judgment and in the best interest of the patient. The invasive nature of the surgery with respect to its involvement of the airway and potential for swelling and airway compromise, along with the need for overnight narcotic pain medication, warranted acute inpatient admission. The intensity of services was beyond the scope of an observation level of care.