Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Comminuted Distal Radius/ Ulna Fracture

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is the case of a male patient with no significant past medical history who presented to Emergency Department (ED) with left wrist pain after mechanical fall off his bike the prior day where he landed on outstretched arms resulting in comminuted distal radius/ ulna fracture. The patient denied any other injuries. He was seen at an outside hospital (OSH) and reportedly left the facility against medical advice (AMA) after he was scheduled for surgery. He presented to another hospital immediately after leaving the OSH with complaint of severe pain in his left arm. He was examined by orthopedics and found with notable deformity, overlying swelling and abrasion with no additional injuries reported. Multiple x-rays of the left wrist and forearm demonstrate a displaced distal 1/3 radius fracture and displaced distal ulna fracture. He was anticipated for admission for operative fixation. The patient was placed in a long splint with non-weight bearing and elevation. He was admitted for further evaluation and management of comminuted distal radius/ ulna fracture, left wrist with compartment monitoring, pain control and was scheduled for surgery. He had no acute events overnight. The patient was taken to the operating room and underwent reduction open fixation of internal ulna and internal diaphysis radius for the diagnosis of left distal radius and ulna fracture. He received Ancef and gentamycin intravenous intra-op. The patient tolerated the procedure without complications and was taken to recovery in stable condition. The post-op course was noted as expected. He remained pain controlled with left arm kept in sling and non-weight bearing. The patient was medically cleared for discharge home with instructions to follow up outpatient with orthopedics.

The records show the patient sustained an isolated closed injury to the left upper extremity. It was of low energy. There were no open wounds (this took into consideration the "abrasion"). There was no evidence of another underlying medical condition to warrant treatment. There was no evidence of a compartment syndrome to require monitoring (ie. compartment measurements with continual measurements). There were no reports of inability to tolerate oral pain medication. No specialized diagnostic studies were required. 

There was no evidence of neurovascular compromise. His vital signs were stable (ie. no fever, bleeding). There were no findings to suggest an infection was present. 

The facts were surgery was performed on a semi emergent basis, 3 days after injury and two days hospitalization. There were no medical reasons provided for the admission and length of stay prior to surgery. The services could have been provided at a lower level of care. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission was not medically necessary.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.