Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Traumatic Left-hand Injury
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned, in part.

The patient is a male. He presented to the emergency room with a traumatic left hand injury that occurred.  On admission examination, he was hemodynamically stable with examination documented a left hand laceration involving the extensor tendons with index finger comminuted proximal phalanx fracture.  X-rays documented an olecranon fracture with index finger proximal phalanx fracture.  IV (intravenous) antibiotics as well as Tdap (tetanus, diptheria, and tetanus) vaccine, irrigation with laceration repairs were performed in the emergency room.

Orthopedics evaluated the patient with plan to take to the operating room. Surgical procedures included left elbow irrigation and debridement with tension band fixation followed by ORIF (open reduction internal fixation) left finger. Wound class of proximal phalanx fracture was noted to be clean. The plan was to discharge home and follow up with orthopedic surgeon in 10 days. Ancef was continued postoperative period.

Pharmacist antimicrobial evaluation recommended augmentin 7 days after discharge, per surgery will remain on IV (intravenous) antibiotics and discharge on PO (oral) antibiotics.

Under review is Inpatient Hospital Admission.

The health plan denied coverage of the admission with the contention that treatment could have been provided at a lesser level of care. Appeal letter stated these treatments could not have been performed in the outpatient due to the severity and high risk of complications.

Yes, in part. The Inpatient admission was medically necessary, in part.
Specifically, inpatient admission to the hospital for the first two days of admission is supported, per evidence-based medicine. Guidelines recommend 24 hours of IV (intravenous) antibiotics for an open fracture. Surgery was performed on day one and after 24 hours of IV (intravenous) antibiotics, the patient could have been discharged on day two. The finger fracture was partially closed and irrigated and debrided. If unable to be definitely fixed, then this could be performed as an outpatient. There is no need for continued admission for 5 days of antibiotics.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
The patient sustained open fractures of the olecranon and index finger. These are classified as Gustilo I/II. Current treatment guidelines for this type of open fracture recommend 24 hours of IV (intravenous) antibiotics. In this case, the patient's olecranon fracture and hand fracture could be treated in the same operative setting, there is no reason to perform as separate cases.  The patient underwent surgical treatment on day one, and evidence-based medicine recommends 24 hours of IV (intravenous) antibiotics. Therefore, the patient could have been discharged on day two after antibiotics completed.

If the hand fracture was unable to be fixed in the same setting, it could have been performed as an outpatient procedure after the recommended IV (intravenous) antibiotics were given.