Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Inpatient Hospital

Diagnosis: Displaced Fracture of Lateral Condyle of Unspecified Tibia, Subsequent Encounter for Open Fracture Type I or II with Malunion
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female who initially presented to the emergency department with concerns of continued right lower extremity pain. Her pertinent history included a recent right tibia fracture that was treated with a knee immobilizer, Ehlers Danlos Syndrome, and panic attacks. Her initial vital signs revealed a temperature of 36.7 degrees Celsius, a heart rate (HR) of 70, a blood pressure (BP) of 136/84, a respiratory rate (RR) of 18 and her peripheral capillary oxygen saturation (SpO2) was 98 percent (%) on room air. The patient's initial laboratory testing revealed a white blood cell count (WBC) of 5.7, a hemoglobin (Hgb) of 13.1 and her platelets (Plt) were 317. Her sodium was 139, her potassium was 4.9, her blood urea nitrogen (BUN) was 9.7, her creatinine was 0.7 and her glucose was 93. 

The x-ray of the right tibia/fibula revealed a nondisplaced oblique fracture of the proximal tibia extending medially from the tibial plateau. The duplex ultrasound did not reveal a deep vein thrombosis. The computed tomography (CT) of the lower extremity revealed findings consistent with Schatzker type IV fracture of the proximal tibia with involvement of the medial and lateral tibial plateau. Orthopedic surgery consulted, they ruled out compartment syndrome, and recommended continued non-operative management. The treatment plan included supportive care including Toradol as needed. The patient felt improved and requested discharge. The attending physician cleared the patient for discharge.

No, the inpatient hospital admission is not medically necessary. Based on the clinical documentation provided, evidence based literature and standards of care, an acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care.
Mthethwa et al. notes, tibial plateau fractures form a wide spectrum of injuries presenting varying challenges to the trauma surgeon. The prognosis of this injury spectrum is largely dependent on the management of each particular configuration. The management of specific injury patterns is based on the Schatzker classification which is a widely accepted traditional classification system. The majority of fractures will require operative management, and with whatever management strategy employed, the main emphasis is on respecting the soft tissue envelope.[1]

The patient had a known right tibia fracture treated with a knee immobilizer who presented to the emergency department with ongoing pain. The initial evaluation found the patient to be afebrile, hemodynamically stable, and without significant laboratory abnormalities. Imaging did not reveal a new or worsening process. Orthopedic surgery consulted, ruled out compartment syndrome, and recommended continued non-operative management. Treatment included primarily non-opiate analgesia and therapy services. Following observation, the patient felt improved and was discharged. No other issues or complications were documented. The patient did not have a vertebral fracture requiring observation for instability or neurologic compromise, compartment syndrome, or a major injury requiring inpatient stabilization such as traction initiation or external fixation before internal fixation or closure. The patient did not have a major injury requiring inpatient treatment after emergency or observation level care, a limb-threatening injury, or severe pain requiring acute inpatient management.[2]