Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right elbow olecranon fracture
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. The reason for the review is that the patient's inpatient admission was denied by the health plan because of lack of medical necessity. 

There is an appeal letter which notes that the patient underwent biopsy, curettage, ORIF (open reduction internal fixation) with bone graft, and was admitted for postoperative antibiotic and pain management.

The patient is a male with a right elbow olecranon fracture. The x-ray showed a pathological fracture and bone defect. The patient underwent the open biopsy and ORIF (open reduction internal fixation) with bone graft by orthopedics. The patient tolerated the procedure well without consultation. Postoperatively the patient was placed in a splint. The patient was extubated, transferred to the PACU (post anesthesia care unit) in stable condition. The patient was given a nerve block for pain control. Perioperative IV (intravenous) antibiotics were ordered for 24 hours. Mechanical DVT (deep venous thrombosis) prophylactics were ordered. The patient remained hemodynamically stable. The patient complained of 10 over 10 pain which was controlled with pain regimen and adjustment of the splint. His vital signs were stable and he was tolerating diet.

Inpatient discharge record notes that the patient he cleaned and underwent same-day elective surgery of the right elbow open biopsy, curettage and oriented with bone graft and interscalene block. He tolerated the procedure well and was placed in a splint postoperatively. No complications were noted. It was noted that the patient was to receive 24 hours IV (intravenous) antibiotics and plan for discharge thereafter. His hematocrit was 39.1. Per the presurgical history and physical exam the patient has no pertinent past medical, past surgical pertinent family history. Patient is a former smoker.

Per the orthopedic postop check day one, the patient's pain is controlled. He denies chest pain, shortness of breath, nausea or vomiting. Patient has voided postop. Vital signs are stable.

Per orthopedic progress note day two, the patient had pain that morning. His splint was adjusted and pain well controlled. The patient was comfortable. He denies chest pain or shortness of breath. Vital signs are stable.

Per orthopedic progress note day three, there were no acute events overnight. The patient's pain is controlled. He denies fever, chills, shortness of breath, chest pain nausea or vomiting. Vital signs are stable.

No, the Inpatient admission was not medically necessary.
Based on the records provided, there is no documentation of a postoperative complication necessitating inpatient admission status such as chest pain, shortness of breath, uncontrolled pain, hypertension, hyperglycemia, or unstable vital signs. There is no documentation of an intraoperative complication or infection necessitating greater than 24 hours of antibiotics or care.

The purpose of the admission was to evaluate the patient's status.  This could have been performed at a lower level of care. The generally accepted standards of medical practice for a patient without complications would include observation status. Inpatient admission status for a patient without documented complications or other factors necessitating inpatient care is not clinically appropriate. An inpatient admission is more intensive than an alternative service such as observation status, which is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's illness, injury or disease.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Based on the records provided, there is no documentation of a postoperative complication necessitating inpatient admission status such as chest pain, shortness of breath, uncontrolled pain, hypertension, hyperglycemia, or unstable vital signs. There is no documentation of an intraoperative complication or infection necessitating greater than 24 hours of antibiotics or care.