Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple injuries from motor vehicle accident.
Treatment: Inpatient hospital admission.

The insurer denied the inpatient hospital admission.  The denial is upheld.

The patient is a male who was injured in a motor vehicle accident, motorcycle. Significant injury to the right knee was noted along with diagnosis of bilateral knee dislocations, pelvic ring disruption, sacroiliac joint disruption right shoulder rotator cuff injury right clavicle fracture.

The patient had been treated with extensive surgery initially, yet was admitted for surgery for the right knee. Right knee anterior cruciate ligament reconstruction with partial lateral meniscectomy, allograft posterior lateral corner surgery was undertaken. After the initial injury, for which surgeries and been undertaken, the patient was transferred to a skilled nursing facility and then brought back to the hospital for surgical intervention. The operative note indicates right knee arthroscopy hamstring anterior cruciate ligament reconstruction with internal brace with posterior lateral corner reconstruction. The surgical note itself indicates no aspect of any significant bleeding, with the surgical procedure performed without complications.

The patient was hospitalized. With respect to medical necessity in regards to admission, it was noted that the patient be kept overnight due to issues of pain control and the possible need for IV (intravenous), IM (intramuscular) pain medications. In addition, this patient was non-weight-bearing on the other three extremities because of the severe injury.

The patient's significant medical comorbidities included scapular fracture, clavicle fracture, bilateral dislocation, pelvic ring fracture with dislocated sacroiliac articulation, and rib fractures.

No, the inpatient hospital admission was not medically necessary.

While the surgery was reasonable, given the multilevel ligamentous knee injury, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

Although this individual and had multiple other injuries, including fractures that have been treated previously, this patient had been discharged to a skilled nursing facility and was brought back to the hospital for an outpatient surgical procedure. The rebuttal to the non-certification simply stated that admission was necessary for the possibility of IV/IM pain medications. Certainly this was not noted and with the anesthesia record reviewed or the surgical note reviewed. There was no complication present that would support the need for the inpatient admission that was undertaken. Although it was noted that this individual had significant comorbidities of other orthopedic injuries, such as a pelvic injury and upper extremity fractures, these were stabilized, and therefore there was no clear indication for which the extended stay was medically necessary, based upon the ODG (Official Disability Guidelines) guidelines for this type of condition, and for the surgery that was performed. Therefore the plan did act reasonably, with sound medical judgment, and in the best interest of the patient in regards to the denial for the inpatient admission for this individual given the type of surgery performed.