Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Contusion of the right lung. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a male patient with a history of myocardial infarction, an angioplasty with 2 cardiac stents, and hyperlipidemia. The patient presented to the Emergency Room (ER) with complaints of right knee pain after falling. The patient was unable to bear weight on the right lower extremity (RLE). The patient's blood pressure was elevated. The patient's computed tomography (CT) scan of the lungs revealed findings that were consisted with a right lung contusion. The patient's physical examination revealed moderate effusion and edema of the right knee; the right knee was tender to palpation and the patient was unable to do a straight leg raise of the RLE. The patient was given 500 milliliters (ml) intravenous (IV) bolus and a diphtheria-pertussis-tetanus vaccine. The patient was admitted to the medical surgical unit with a contusion of the right lung. 

The patient was given IV fluids at 100 milliliters per hour (ml/hr) and deep vein thrombosis (DVT) prophylaxis was maintained. The patient's labs were trended. On day 2 of admission, pulmonary services consulted over the case, and they noted that the pulmonary contusion was minimal. Use of an incentive spirometer, supportive care, and continued DVT prophylaxis were recommended. The patient's magnetic resonance imaging (MRI) of the knee revealed a tear of the proximal patellar tendon, lateral and patellofemoral compartment chondrosis, and horizontal tears of the posterior horns of the medial and lateral menisci. The patient was taken for urgent surgery on day 3 of admission. The patient underwent a patellar tendon repair and medial and lateral retinaculum of the right knee. The patient was given an American Society of Anesthesiologists (ASA) class score of III. Neurovascular status, intake and output, pain level, and hemodynamic stability were monitored after surgery. Oxycodone and Ultram were given for pain management. A physical therapy (PT) evaluation was done and continued outpatient PT was recommended for the patient. The care plan was implemented and the patient was discharged on day 4 of admission after a period of medical stability. The patient was instructed to follow up with the primary care physician, orthopedic surgeon, and critical care medicine within one week of discharge. 

Based on the review of the medical record and literature, the inpatient admission was not medically necessary for this patient. The patient sustained an isolated patella tendon rupture. Although the patient's CT scan reported possible pulmonary contusion, there was no clinical correlation. For instance, there was no subjective complaint of chest pain, rib pain or shortness of breath. There were no objective findings on physical examination. The patient's chest exam was non-tender, and pulmonary exam revealed breath sounds clear and equal. There was no conclusive imaging study that showed acute chest pathology. A differential diagnosis was provided for opacity. The etiology was unclear. The patient's pulse oximeter measured 98% which would not be consistent with acute chest trauma. These clinical findings do not support the basis for an acute pulmonary problem to complicate medical care. The patient's surgical procedure was not complex or extensive. There was no evidence of postsurgical problems. The patient's postoperative course was stable. There was no evidence of pain, fever, infection or bleeding. There were no underlying medical conditions to require inpatient level of care. These facts do not support the need for an acute level admission. Observation status would have been appropriate for this patient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.