Appeal type: Medical necessity
Decision: Overturned

The patient is a male with a history of diabetes and hypertension who presented to the Emergency Department via emergency medical services with the complaint of gunshot wounds to his bilateral lower extremities. The patient reported being in an argument with an acquaintance that escalated, and the acquaintance shot him multiple times. He was seen by multiple physicians, including the emergency physician, trauma surgeon, and orthopedic surgeon. Aside from a mildly elevated blood pressure reading, his vital signs were within normal limits. His Glasgow Coma Scale was 15. His mood was boisterous, and he was cooperative and talkative. He appeared distressed according to the documentation. His airway was intact, and he was breathing normally. His initial assessment revealed 4 wounds: 1 on the medial aspect of the right ankle, 1 on the lateral aspect of the right ankle, and 2 on the base of his left foot. His pulses were intact, he had normal sensation, and normal strength. He received 1 liter of 0.9 normal saline intravenous (IV) fluid, two doses of IV fentanyl, IV Ancef, and a tetanus shot while in the Emergency Department.
He had basic trauma labs performed which revealed an elevated alcohol level, a mildly elevated creatinine (baseline unknown), and an elevated lactate level. Multiple x-rays were performed and revealed a comminuted fracture of the proximal fibula on the left and a posterior medial distal tibial fracture on the right. His wounds were irrigated, and he was placed in bilateral short leg splints. He screened positive on the CAGE (cut-annoyed-guilty-eye) questionnaire for alcohol use disorder. He was admitted to the trauma service for pain control, monitoring, psychiatric evaluation, and physical therapy (PT) evaluation. It was not felt that surgical intervention was necessary. He was to be non-weight bearing until switched to a controlled ankle movement (CAM) boot on the left, at which point he could bear weight as tolerated. He was to have his legs elevated and use ice for swelling. Sometime during the day the orthopedic service decided to get a computed tomography (CT) of the right ankle in order to rule out intra-articular extension of the fracture in order to see if he could be made weight bearing as tolerated on the right side as well. This was done and after he had his initial PT evaluation. During the initial PT evaluation, the patient was not able to safely use crutches and it was recommended that he use a rolling walker. The CT of the ankle was ultimately negative for extension of the fracture in to the joint and orthopedics felt he could bear weight as tolerated on both sides. He was seen and cleared by the psychiatry service. He was seen by PT again and was able to safely use crutches at that time. His pain was well controlled with oral medications during his stay in the hospital. The patient was discharged home in stable condition.

The health plan's determination is overturned. 

Yes, an inpatient stay was medically necessary for this patient. He required further evaluation beyond his initial stabilization and treatment in the Emergency Department in order to ensure a safe discharge.
The patient was unable to use either of his legs at the time of admission due to bilateral non-weight bearing instructions from the orthopedic team. He had been receiving IV pain medications while getting his initial assessment, and it was unclear how well he would tolerate pain during his stay. He required placement of a CAM boot, a physical therapy/rehab evaluation, further imaging, and psychiatric evaluation in order to ensure a safe and appropriate discharge. The patient came to the hospital at 1 o'clock in the morning, and his evaluation was not completed until several hours later. In fact, the patient did not do particularly well on his initial PT evaluation, at which time he was still only allowed to bear weight as tolerated on his left leg, and he could not use crutches. It was recommended that he ambulate only with a rolling walker. Ultimately, a CT of his ankle was required to find out if he could safely be allowed to bear weight on his other leg. This was a very important determination, as early ambulation and weight bearing facilitate rehabilitation and improve patient outcomes, including reduction of risk for venous thromboembolism (1). On re-evaluation by PT, he was able to use crutches safely with the new weight bearing recommendations.