Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Hand Second and Third Digit Laceration ( s/p surgery)
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the proposed inpatient admission is not "medically necessary".

The patient is a male with no significant medical history, presented to the Emergency Department after a trip and fall down two steps while holding a glass. The patient sustained a finger laceration of the second and third digits of the right hand. 

In the ED he underwent lab work and x-ray of the right hand. No acute fracture was noted, and no foreign body visualized. He was evaluated by Plastic Hand Surgery who noted a transversely oriented laceration just beyond the MCP (metacarpophalangeal joint) on the middle level of the proximal phalanx of the right hand. The patient had paresthesia along the ulnar aspect and limited paresthesia along the radial aspect. The patient was unable to actively flex the fingers. The wound was irrigated and explored in the Emergency Department but due to likelihood of tendon and nerve injuries operative exploration and repair was advised. 

The patient was admitted to Trauma Surgery with a diagnosis of Right Second- and Third-Digit Lacerations and associated Flexor Tendon Injuries with the following orders: nothing by mouth after midnight, intravenous fluids, IV Ancef pre-operatively, acetaminophen for pain, and Type and Screen. He was taken to the OR (operating room) for Primary repair of zone 2 flexor tendon injury of the right hand and repair of the nerve of the right hand. Findings included injury to the digital branch of the medial nerve FDS and FDP. Postoperative orders included intravenous fluids, oxycodone every 4 hours for pain, IV Zofran for nausea and vomiting, regular diet as tolerated, and right hand with dressing and sling in place. His pain was controlled on oral analgesics and his diet was advanced. He was later deemed stable for discharge home with instructions to follow up with Plastic Surgery as an outpatient.

Admission was not medically necessary. Tendon and nerve repair is an outpatient procedure. Other than the management of severe infections, admission is almost never required prior to or following hand surgery procedures. Almost all hand surgery procedures can be performed at an outpatient level of care. According to the MCG 24th Edition, Ambulatory Surgery or Procedure GRG: Potentially ambulatory[A] surgery or procedure covered by this guideline (ie, not covered more specifically by another guideline)[B] may proceed on an ambulatory[A] basis due to the absence of Ambulatory Surgery Exception as indicated by ALL of the following:
No inpatient care needed for preoperative disease or condition
Not emergent procedure
No complex surgical approach or situation anticipated
Low-risk procedure or patient not at high anesthetic risk
No drug-related risk
No inadequate outpatient care situation

This was a healthy male who underwent a procedure that is commonly performed as an outpatient. The procedure was not emergent. Flexor tendon and digital nerve repairs can be safely deferred for up to 5-7 days.  The approach was not complex. The procedure was low risk and the outpatient situation was adequate. Admission was not required for this straightforward hand surgery procedure. 

According to the Milliman Care Guidelines, 24th Edition, "General Admission Criteria", Admission is indicated for 1 or more of the following:
Hemodynamic instability
Hypertension requiring inpatient treatment
Acute cardiac or peripheral ischemia
Cardiac arrhythmias of immediate concern
Severe heart failure
Respiratory abnormalities
Severe airflow or ventilation abnormalities
Impending or actual respiratory arrest
Neurologic abnormalities
New-onset severe neurologic findings
Suspected acute intra-abdominal process
Severe physiologic disorder
Abdominal abnormalities
Acute renal failure
Significant uremic complications
High fever or other high-risk infection situation
Temperature less than 90 degrees F (32.2 degrees C) (rectal)(61)
Severe nutritional abnormalities
Severe electrolyte abnormalities
Acute blood loss causing significant abnormality
Severe anemia
High-risk low platelet count
Disseminated intravascular coagulation
Severe adverse drug or systemic toxin reaction requiring inpatient treatment
Severe pain requiring acute inpatient management
Severe behavioral health issues
Inpatient monitoring needed; examples include:
- Vital signs, neurologic signs, or vascular checks more frequently than every 4 hours
- Cardiac or respiratory monitoring beyond the scope (eg, over 24 hours) of observation care
- Pulmonary artery catheter monitoring
- Suspected compartment syndrome
- Cerebral bleeding, hydrocephalus, or vasospasm monitoring
- Increased intracranial pressure or cerebral edema monitoring
- Fetal monitoring
Treatment requiring inpatient care; examples include:
- IV fluid to replace significant ongoing losses (greater than 3 L/m2 per day)
- High concentration oxygen (greater than 40%)
- Frequent respiratory therapy (more frequently than every 4 hours) to maintain airflow rates greater than 60% of baseline
- Epidural analgesia(83)
- IV anticoagulation, vasoactive, or antiarrhythmic medication
- Acute thrombolytics (generally require 24 hours of observation)
 Emergency procedures needed

This patient did not have any of these conditions. He had pain following the surgery but was hemodynamically stable. His pain was controlled with analgesics. He did not have any significant physiologic or surgical complications following the procedure.  He could have been managed at an outpatient level of care.