Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip arthroplasty.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult female. This was previously denied for medical necessity. 

The patient's past medical history is significant for anxiety, arthritis, chronic cough, depression, fibromyalgia, hypertension, osteoarthritis, pancreatitis, recurrent UTIs (urinary tract infections), and shortness of breath on exertion. The patient was scheduled for total hip replacement.

Per the orthopedic progress note postop day #1: No events overnight. Pain is well-controlled. Left hip pain radiating to the left buttock and shin. Ambulated with PT (physical therapy) 20 feet and then 30 feet with a contact guard.

The orthopedic progress note the next day stated that the patient's pain was controlled.

Per the orthopedic progress note the following day, the patient's pain was well-controlled. No events were reported overnight. The patient walked to the bathroom, got back into bed, and felt a pulled muscle.

Per the postop day #3 note, no acute events were reported overnight. The patient's pain was well-controlled. She ambulated 100 feet. X-ray of the left hip shows no fracture or dislocation. The plan is to discharge to rehabilitation.

The patient was discharged to rehabilitation on postoperative day #6. The orthopedic progress notes no events were documented overnight.

Per the discharge summary concerning Discharge diagnoses/hospital problems for resolved problems, there were no resolved hospital problems. Other comorbidities were intact. In summation, nothing is documented. The discharge summary notes that the patient's hospital course was uneventful/uncomplicated, however, she was seen by psychiatry for anxiety.

The inpatient admission was not medically necessary.
The inpatient admission was not in accordance with the generally accepted standards of medical practice. Based on the records provided, there is no documentation that the patient's medical condition, safety, or health would have been significantly and directly threatened if care were to have been provided in a less intensive setting.

Per CMS (Centers for Medicare and Medicaid Services) Program Integrity Manual, "Inpatient care, rather than outpatient care, is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting."

The inpatient admission was not clinically appropriate, in terms of its type, frequency, extent, site, and duration and was considered effective for the patient's injury and pathology. Factors that would only cause the patient or patient's family inconvenience do not justify a continued hospital stay.

Per CMS (Centers for Medicare and Medicaid Services) Benefit Policy Manual, "An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as an inpatient with the expectation that he or she will require hospital care that is expected to span at least two midnights and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not use a hospital bed overnight."

There is nothing in the documentation to suggest the procedure was mainly for the convenience of the doctor or other healthcare provider.

The inpatient admission was more intensive than an alternative of care that is at least likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's sickness, injury, disease, or symptoms. Based on the records provided, the patient could have been provided care in a less intensive setting in the hospital, such as observation.