Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The denial is upheld in whole.

The patient is a male who presented to the emergency department (ED) with ankle pain after having slipped on ice and fallen onto his left ankle. He was hemodynamically stable on presentation. On physical examination, he was found with significant left ankle swelling and deformity with bony protrusion and skin tenting. Ankle computed tomography (CT) showed a comminuted fracture of the distal tibia that was displaced for a distance of 22 millimeters (mm). There was an attempt to reduce the dislocation in the ED. Follow up x-ray showed that the distal portion of the left tibia was anteriorly displaced. There was then a second attempt to reduce the dislocation. The injury was splinted. Repeat imaging showed improved alignment of the ankle joint. The Orthopedic surgeon on-call felt that the injury required referral to a foot and ankle specialist. The surgeon was concerned about swelling due to the severity of the injury. The patient's pain was treated with morphine, Dilaudid and fentanyl. Motrin, Tylenol and Toradol were also ordered. The patient was noted to have a necrotic lesion to his right big toe and had apparently been on outpatient antibiotics for this. His leukocyte count was elevated at 13.1. He was given Vancomycin and Rocephin. It was discovered that patient was homeless. It was decided to admit the patient for further treatment including intravenous (IV) antibiotics, physical therapy (PT) and crutch training, and social work (SW) consult. Podiatry was consulted and recommended local wound care for the patient's necrotic toes and outpatient podiatry follow up. Psychiatry was consulted to evaluate the patient's anxiety. The patient was accepted for transfer to another hospital where he could be seen by an ankle and foot specialist for further evaluation and consideration of surgical intervention. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld in whole.

Inpatient stay was not medically necessary for this patient. The patient could have been managed at a lower level of care status.

He did not meet Milliman Care Guidelines (MCG) for admission for a fracture, as he did not have a limb-threatening injury and there is no indication that the patient had pain that was uncontrolled with oral medications. His pain was already much improved on presentation to the ED, per notes. He required the IV analgesics in relation to the reduction attempts, but otherwise did well on by mouth (PO) medications. Per literature, ankle fracture patients not undergoing surgery and treated with conservative measure can experience less pain and better functional scores than patients that undergo surgery. Because it wasn't known if the patient would require surgery, he could have remained at the lower level of care status until he was seen by the ankle and foot specialist. At that point if it were decided the patient required surgery, it would be reasonable to change him to inpatient status. Although the patient was given a dose of IV antibiotics in hospital, he was not septic or hemodynamically unstable. He was not being treated for osteomyelitis. Consideration is made for the fact that the patient is homeless. He did require admission so that a social work consult could be made to help address his social situation, however this could have been done at a lower level of care status.