Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Knee Dislocation and Left Patellofemoral Dislocation

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a female who was admitted to orthopedic service after sustaining a left knee dislocation and left patellofemoral dislocation. The patient was transferred from an outside hospital to this higher level of care. On the day of arrival, the patient underwent a left knee examination under anesthesia, closed reduction of the patellofemoral joint, closed reduction of the knee joint, and left knee multiplanar external fixator with an estimated blood loss of 25 milliliters. The procedure was uncomplicated and she was transferred to the Post Anesthesia Care Unit and then orthopedic floor in stable condition. The patient was seen by Vascular Surgery to rule out any tear of the popliteal artery. This was ruled out and was negative. The patient was encouraged to get out of bed and was seen by physical therapy and occupational therapy. She underwent pin care 3 times a day with half-strength Peroxide. She was continued on weight-based deep vein thrombosis prophylaxis. The patient's pain was controlled throughout the hospital course with oral pain medications. She continued to increase her mobilization and continued to work with physical therapy and occupational therapy who recommended rehab given patient's inability to safely mobilize or ambulate up and down stairs. The patient was discharged. 

This woman has a complex and significant medical condition. At the very least she sustained a multi ligamentous knee injury with dislocation to patella. It had reduced on its own. She was morbidly obese with a body mass index over 45. This would produce more injury as the increased weight would fall upon her knee. She was found to have an injury to her peroneal nerve. She would be unlikely to ambulate. 

She required several diagnostic studies to evaluate her vasculature and other soft tissues. An injury such as this is associated with intimal tears to the popliteal artery. The condition may not manifest itself upon presentation. The condition can result in later thrombosis which requires monitoring. Initial diagnostic testing may not demonstrate the pathology. 

Additional surgery would be a serious concern based upon mechanism of injury and clinical course (ie. Vascular procedure if thrombosis or blockage occurred, orthopedic surgery if the external fixator did not provide stability). 

In addition, the woman had an extensive psychiatric history and required consultation and ongoing management. 

In conclusion, based upon the clinical history of trauma, diagnosis of nerve injury and dislocation, morbid obesity and psychiatric treatment, these services could not have been provided as outpatient or Ambulatory Surgical Unit.  All admission and length of stay would thus be necessary and appropriate. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is reversed. Medical necessity is substantiated.