Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hindfoot valgus deformity
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is an adult female. She underwent surgery as an outpatient, and was then converted to an inpatient setting. The need for pain management, slow progression due to physical therapy and comorbidities of rheumatoid arthritis was noted. Because of pain secondary to medial arch pain of the foot, ambulation was limited. The patient's clinical examination had demonstrated a substantial hindfoot valgus deformity, stiffness is severe, and big toe pain varus deformity. Limited motion of the hindfoot was appreciable with hindfoot valgus noted. Prominent plantar flexion of the talus and dorsal positioning of the navicular was noted on x-rays with advanced arthrosis over the lateral aspect of the ankle joint. Surgery was to be staged with a toe component and later total ankle replacement. Medical clearance had been obtained for which it was noted that she was an elevated risk for perioperative complications given the juvenile rheumatoid arthritis, chronic immunosuppression, mild abnormal EKG (electrocardiogram) with prior history of prosthetic joint infection requiring chronic antibiotics. Records note that treatment had included a right subtalar fusion talonavicular fusion on the right with right iliac crest bone graft posterior calcaneal osteotomy. The following day the block had
begun to wear off. Pain control was with Tylenol and oxycodone. Pivot steps were undertaken with minimal assist due to pain and limited the ability to function, limited by fatigue.
On the following day the patient was able to ambulate 5 steps with a walker, 40 feet with a knee walker and transferred independently. The patient was medicated for pain for which it was felt she was able to be discharged to home.

The requested health service was medically necessary.
As noted within an article in Advanced Therapeutics, in regard to perioperative management of patients with inflammatory rheumatic diseases (1), "Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint
involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage
a multidisciplinary approach. The frequent association with extra-articular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases."
The comorbidities noted include diabetes, history of periprosthetic infection for knee replacement that required chronic intermittent use of antibiotics, obesity, and
chronic pain. This patient had problems associated with ambulation as was noted within the documentation. Because this patient was not able to ambulate and had difficulties in doing such, the hospitalization that was necessary. Converting an outpatient to an inpatient setting was medically reasonable/appropriate. Noted under the ODG (Official Disability Guidelines) guidelines with destructive ankle lesion, for an individual with rheumatoid arthritis, the significant arthritic changes as noted within the records reviewed would indicate that with this destructive lesion, the length of stay for treatment, surgical treatment best practices would be four days. Although this was certainly considered as an outpatient surgical procedure, the postoperative complications and the perioperative issues that were clearly noted support the hospital length of stay that was undertaken as medically reasonable.