Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right hip dislocation and equinus contractures. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is the case of a male with a history of mixed/dystonic cerebral palsy (CP), bacterial meningitis, refractory seizure, and right hip dislocation and equinus contractures. The patient was admitted. 

As per the preop History & Physical, the patient is a male with mixed dystonic CP, Gross Motor Function Classification System (GMFCS) level 5 from bacterial meningitis at an early age, refractory seizure with right hip dislocation. He has equinus contractures bilaterally. He cannot sit independently. He is non-verbal and is not ambulatory. He attends a special education school with 3x (times)/week physical therapy (PT), occupational therapy (OT), speech language pathology (SLP). He is fed via gastrostomy tube (GT) on a ketogenic diet. He has a history of reactive airway requires bronchodilators with viral illnesses. He is also nothing by mouth (NPO) due to history of swallowing dysfunction. He is small for his age. He is preop for bilateral varus osteotomy (VRO), bilateral adductor tenotomy, bilateral gastrocnemius resection, right pelvic osteotomy, right hip reduction, spica cast. Neurology cleared the patient for surgery. Pulmonary evaluation noted that he has a high risk from respiratory status in setting of neuromuscular disease. He was cleared for surgery by endocrinology. The Pediatric Intensive Care Unit (PICU) was booked for postop management as there is a high risk for pulmonary complications secondary to respiratory insufficiency for underlying neuromuscular disease, anesthesia, and risk of pneumonia. 

Based upon the information provided, the patient met criteria for surgery and for inpatient admission given his multiple medical co morbidities and the required surgery. The procedure that the patient underwent is NOT an ambulatory procedure. It is an inpatient procedure and the child needed to be transferred afterwards to the PICU at another hospital for further care until he could be transferred back to the original hospital. 

According to MCG (Milliman Care Guidelines) Health General Recovery care 26th Edition: Musculoskeletal surgery or procedure... Surgery or other procedure covered by this guideline is indicated for 1 or more of the following: Vertebral fracture with evidence of instability or pending instability (e.g., neoplastic lesion of spinal column, compression fracture with spinal canal compromise); Osteoporotic vertebral fracture; Cervical spine fracture; Thoracic vertebral fracture; Lumbar vertebral fracture; Thoracic radiculopathy (e.g., herniated disk); Thoracic myelopathy (e.g., herniated disk); Need for procedure due to thoracic spine tumor; ... Musculoskeletal Surgery or Procedure AND 1 or Pediatric General Admission Criteria or Procedure is usually performed on an ambulatory basis, but inpatient stay is needed.  

The procedures this patient underwent are inpatient procedures and therefore inpatient admission was warranted. Nevertheless, the procedure is considered an inpatient procedure. 

The patient therefore did meet the criteria to necessitate acute inpatient admission as the lengthy procedure the patient underwent is an Inpatient procedure and not one done as an ambulatory/observation case. Based upon these guidelines this patient could not have been observed but rather than an inpatient admission as he did have indication as noted above for inpatient admission. 

Thus, the justification is present for this patient to be admitted for this procedure and then to be transferred for further care until he could be transferred back. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.