Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Leg surgery.
Treatment: Inpatient hospital admission.
The health plan denied: Inpatient hospital admission.
The determination is: Overturned.

The patient is a female who was diagnosed with congenital bowing of the right tibia, bone cyst, mononeuropathy of right lower extremity, and nontraumatic compartment syndrome of right lower extremity. There is a preoperative medical evaluation stating that the patient has had right hip pain for 5 years and right ankle pain for 6 months. The pain was rated 7/10. The surgical history includes bilateral knee arthroscopy, laminotomy, and lumbar discectomy. The comorbidities include asthma, autoimmune disease, bilateral external tibial torsion, gastroesophageal reflux disease, osteoarthritis, osteoporosis, iron deficiency anemia, migraines, Sjogren's disease, rheumatoid arthritis, and vertigo. The body mass index (BMI) is 36. The vital signs were stable. Her vitamin D was low. There is a history of reaction to anesthesia (tachypnea and rash). There were no absolute medical contraindications to the planned procedure.
The operative report states that a right tibia and fibula osteoplasty, insertion intramedullary nail to the right tibia, neuroplasty right common peroneal nerve, fasciotomy right lower leg anterior, lateral, and posterior compartments, and gastrocnemius recession was performed. Another postoperative note states that the plan was for physical therapy, a nonweightbearing status, deep vein thrombosis (DVT) prophylaxis with aspirin, and to continue the current pain management regimen with a goal to discharge home on postoperative day 3 provided the pain is controlled and the patient is cleared by physical therapy. A chronic pain rounding note states that the pain was well-controlled. The patient endorsed right lower extremity numbness. The medication list includes pregabalin, aspirin, tizanidine, and tramadol. It is noted that the pain was managed with epidural patient-controlled analgesia (PCA) due to a history of multiple drug allergies. The plan was to extend the epidural PCA until 9 in the morning the following day. The chronic pain rounding note states that the Marcaine PCA was discontinued, and the patient received oral tramadol once. The pain was rated 0-4/10. The plan was to discharge home.
At issue is the medical necessity of the inpatient full hospital admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of full hospital admission is medically necessary for this patient.
In this case, the patient had congenital bowing of the right tibia, a bone cyst, mononeuropathy of right lower extremity, and nontraumatic compartment syndrome of the right lower extremity. There are significant comorbidities including asthma, autoimmune disease, bilateral external tibial torsion, gastroesophageal reflux disease, osteoarthritis, osteoporosis, iron deficiency anemia, migraines, Sjogren's disease, rheumatoid arthritis, vertigo, and obesity (BMI 36). There is a history of a reaction to anesthesia (tachypnea and rash), and there also is documentation of multiple severe drug allergies. The surgery performed involved a right tibia and fibula osteoplasty, insertion intramedullary nail to the right tibia, neuroplasty right common peroneal nerve, fasciotomy right lower leg anterior, lateral, and posterior compartments, and gastrocnemius recession. The postoperative care involved continued pain management with epidural PCA, which was discontinued appropriately, at which time the patient was discharged home on oral medications and in stable condition. In this case, the postoperative care requirements could not be met, even initially, in an alternate surgical setting. Given the complexity of the preoperative condition, associated comorbidities, and drug allergies, the inpatient level of care was appropriate.