Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Charcot Ankle, s/p (status post) Left Limb Salvage Procedure. 
Treatment: Inpatient Hospital Admission. 
The health plan has denied the inpatient hospital admission. 
The health plan's determination is upheld. 

This is a male diagnosed with left Charcot ankle. There is a request regarding inpatient care. A history and physical documented that the patient suffered an injury after a fall a few years ago to the left ankle. They have had worsening pain and difficulty ambulating. They presented for a limb salvage procedure due to a Charcot ankle. They have comorbid diabetes and hypertension. An exam of the left lower extremity documented an antalgic gait, and a medial wound 3 x 2 centimeters (cm) over the talonavicular joint, reduced sensation, severe hindfoot valgus with forefoot abduction, and inability to inverter either at the ankle, and no tenderness. There is a plan for a 1st stage left limb salvage procedure with debridement, deformity correction, and external fixation placement. An operative note documented that the patient underwent left Charcot ankle reconstruction with application of a multiplanar external fixation device. A postoperative note documented that the patient was status post left ankle surgery with no new complaints. Pain was well-controlled. The provider recommended admission, continued monitoring, weight-bearing as tolerated, Physical and Occupational Therapy, pain control, and deep vein thrombosis (DVT) prophylaxis. A pain management consultation documented that the patient underwent left ankle reconstruction and pain was controlled with a popliteal catheter. The provider recommended continuing a catheter, by mouth (PO) oxycodone, and PO acetaminophen. An orthopedic note documented that the patient was resting comfortably. They ambulated 15 feet with Physical Therapy. The health care team stated a discharge was pending Physical Therapy clearance. A pain management note recommended continuation of the current care plan of a popliteal fossa catheter, acetaminophen, and oxycodone. An orthopedic note documented that the patient denied pain. They walked 50 feet with Physical Therapy. A pain management note recommended continuing the current medication regimen and pending disposition to remove the patient's catheter as per the primary team. A discharge summary from orthopedics indicated that the patient underwent a limb salvage procedure, completed IV antibiotics, had well controlled pain, was seen by Physical Therapy, and was discharged home. 

The inpatient hospital stay was not medically necessary. 
Current medical literature does not address inpatient stay following limb salvage procedures. In this circumstance, the patient presented for a limb salvage procedure to the left lower extremity which included debridement, deformity correction, and external fixation placement. They have comorbid diabetes and hypertension. They were admitted postoperatively and underwent antibiotics, DVT prophylaxis, pain control with a popliteal catheter and oral medications, physical therapy, and were discharged home. They had no intraoperative or postoperative complications. There is not documentation that the postoperative care provided could not have been done so under an alternate level of care. The patient had no significant comorbid conditions requiring inpatient monitoring and did not have any intraoperative or postoperative complications which required inpatient care.