Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip/pelvic fractures 
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This is an adult patient who presented to the Emergency Department (ED). Vital signs were stable. The patient was brought in by Emergency Medical Services (EMS) after falling off the exam table at the dermatologist's office. Past medical history includes hypertension, hyperlipidemia, supraventricular tachycardia, and Wolff Parkinson White (WPW) status post ablation. The patient's right hip was tender with pain on full range of motion. Trauma was consulted and noted that X-rays showed superior and inferior rami fractures. Trauma noted that the patient has been unable to walk due to pain since the fall. The recommendations were Computed Tomography (CT) of the abdomen and pelvis for further evaluation, and orthopedic consultation. The patient was admitted for further management. Orthopedics saw the patient and recommended right lower extremity Toe Touch Weight Bearing. Physical Therapy (PT) also evaluated the patient who was unable to get out of bed due to pain. PT recommended skilled PT. The patient required oral acetaminophen and intravenous (IV) morphine for pain control. The patient became febrile to 101.5 degrees Fahrenheit. A urinalysis revealed large leukocyte and the white blood cell count was 18. The patient was started on IV (intravenous) Rocephin. After further management of the urinary tract infection (UTI), pain control, and continued physical therapy the patient was discharged to a rehabilitation center for continued physical therapy.

Based upon the information provided, the hospital inpatient admission is justified based on the fact that the patient was in severe pain from the hip/pelvic fracture and could not get out of bed for several days while requiring constant pain medication. The patient subsequently developed a UTI and had a white blood cell count of 18 with high fever requiring IV antibiotics. This added to the need for hospitalization. The patient was eventually discharged to a rehabilitation center for continued physical therapy. Based upon Milliman Care Guidelines (MCG) General recovery care 26th Edition: musculoskeletal disease General Recovery Guideline (GRG) GRG: MG-MD (ISC GRG)  hospital admission is needed for appropriate care of the patient because of 1 or more of the following: Newly diagnosed or suspected bone, joint, muscle, or orthopedic device infection (such as periprosthetic infection, pyomyositis); Vertebral fracture requiring inpatient care; Nonvertebral fracture, dislocation, or other musculoskeletal injury requiring inpatient care (medical), as indicated by 1 or more of the following: Compartment syndrome (proven or cannot be ruled out during observation care), severe pain requiring acute inpatient management due to musculoskeletal condition. Although no operative intervention was done, the patient required inpatient hospitalization for pain management and the inability to ambulate or get out of bed. The patient needed physical therapy and eventually needed to be sent to a rehab center.

The reviewer disagrees with the insurer as the inpatient admission was medically necessary at the acute inpatient level as the patient could not have been sent home and warranted inpatient care given the pelvic/hip fracture and requiring pain medication. The patient was not able to get out of bed or ambulate initially and required inpatient PT and pain management. The denial is overturned. Finally, the reviewer is knowledgeable in this condition and the recommended health care services provided for this condition, as the reviewer does believe that inpatient admission was medically necessary. The denial is therefore overturned. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is substantiated.