Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Finger Injury. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a male. He presented after having sustained an injury to the distal aspect of the middle finger when a door was slammed on the finger.

Emergency department evaluation noted crush injury to the distal middle finger when his finger was slammed in a door. DIP (distal interphalangeal) joint circumferential laceration tendon exposed sensation to the area absent. The patient was to be admitted to surgery with ORIF (open reduction internal fixation) displaced fracture. 

Laceration repair was done with lidocaine 1% (percent) finger with no visualized foreign body present pressure washed was undertaken with sterile saline. Skin was repaired with 3-0 Prolene suture. Splint was applied. Discharge summary described the injury to the finger at the hospital course laceration repaired with interrupted Prolene suture. DIP (distal interphalangeal) joint of the third finger and a circumferential laceration tendon exposed sensation intact. Recommendation was for follow-up hand clinic keeping the wound clean and dry. 

Appeal for denial for inpatient care noted that this individual had a history of cannabis use disorder, schizophrenia, schizoaffective disorder, bipolar presented. In the emergency room crush injury to the right middle finger was noted as a door was slammed on the finger. A circumferential laceration about the right third digit was noted distal aspect of the fingertip was dorsally displaced and it was described with little to no sensation over the tip. X-rays demonstrated a fracture distal phalanx right middle finger with dislocation of the DIP (distal interphalangeal) joint. Consult with orthopedic surgery and then provided with the following day and a reduction internal fixation which necessitated the acute inpatient care. Once stable ruling out sepsis and permanent injury, it was felt the patient was safe for discharge. It was stated this could not be performed in an outpatient setting. This is predicated upon the guidelines meeting the criteria for inpatient hospitalization. It was felt that according to the American Academy of Orthopedic Surgery treatment of the fracture should be emergent in nature. Because of neurovascular compromise digit this individual was not stable to be discharged from the emergency room. Noted is that the patient had been made nothing by mouth after midnight given intravenous antibiotics and then treated the following day. 

Yes, the Inpatient admission was medically necessary. 

No, the health plan did not affect in sound medical judgment and in the best interest of the patient with the open injury described. 
In regards to the criteria for treatment for open injuries, Green's Operative Hand Surgery would indicate that for those individuals for metacarpals as well as phalanges that the indications for surgery would include open fractures that described the following indications. In addition IV (intravenous) antibiotics are necessary: 
1) Irreducible fractures, 
2) Malrotation (spiral and short oblique), 
3) Articular fractures, 
4)Subcapital fractures (phalangeal), 
5) Open fractures, 
6) Segmental bone loss, 
7) Polytrauma with hand fractures, 
8) Multiple hand or wrist fractures, 
9) Fractures with soft tissue injury (vessel, tendon, nerve, skin), 
10) Reconstruction (i.e., osteotomy). 

Based on the above, the proposed treatment, treatment, open reduction internal fixation because of the open injury is supported. 

Noted is that this individual had sustained an open crush injury to the digit. The fractured distal phalanx was described as displaced along with altered sensation about the digit. Because of the displacement of the fracture components, the open injury the patient had been admitted for fixation the following day. It was asserted by the health plan that that this patient could have undergone outpatient surgery. 

The ODG (Official Disability Guidelines) guidelines describes open fractures stating the following: "ODG [Official Disability Guidelines] Criteria Gustilo Classification 
I. Low energy, wound less than 1 cm [centimeter] 
II. Wound greater than 1 cm [centimeter] with moderate soft tissue damage 
III. High energy wound greater than 1 cm [centimeter] with extensive soft tissue damage 
IIIA. Adequate soft tissue cover 
IIIB. Inadequate soft tissue cover 
IIIC. Associated with arterial injury. 

Evidence Summary: 
The ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th edition) diagnostic coding system requires the Gustilo classification. The Gustilo system classifies open fractures into three main categories: Type I, Type II, and Type III, with Type III injures being further divided into Type IIIA, Type IIIB, and Type IIIC subcategories. The categories are defined by three characteristics, including: (1) Mechanism of injury; (2) Degree of bone injury or involvement; & (3) Extent of soft tissue damage. Skin size of laceration is an attempt to quantify the soft tissue injury. A higher grade suggests more energy involved in the injury. Grade IIIC fracture implies vascular injury as well. Gustilo Open Fracture Classification for Ankle and Foot Conditions. 

The criteria would include low energy wound less than a centimeter or wound greater than 1 cm (centimeter) with moderate soft tissue damage. This was a circumferential injury around the patient's digit. This can result in an embarrassment to the vascularity as well as an injury to the nerve. For that, the open treatment of the condition was medically appropriate and reasonable. It could not have have been performed on an outpatient basis but rather an inpatient stay. In addition IV (intravenous) antibiotics were necessary in order to ensure that there is no significant contamination from a wound that can then lead to an infection that can have more devastating complications. 

Also noted under the Millman guidelines: "Postoperative effects not resolved or adequately managed (eg, significant pain or vomiting not appropriate for outpatient or next level of care)." 

With that, the postoperative effects that cannot be resolved can be an infection that should not be treated an outpatient basis, and thereby the condition was not reasonable for outpatient treatment. With the documentation reviewed, the inpatient admission was medically appropriate and reasonable for the treatment that was provided.