Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient services. 
The denial is upheld.

The patient is a male who was involved in a motor vehicle collision. The patient had no significant medical history. This accident resulted in a right distal radius fracture, a right ankle medial malleolar fracture and a left clavicle fracture. Orthopedic surgery was consulted for these injuries and open reduction and internal fixation surgery was performed on the left clavicle fracture, the right distal radius fracture and on the right ankle medial malleolus fracture. The surgery was completed. The neurosurgery service recommended brace treatment for thoracic and lumbar vertebral body injuries. The patient recovered well after surgery and was deemed stable for discharge. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The requested inpatient hospital stay was not medically necessary for this patient. This determination is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature. The provided medical records document that this healthy patient was involved in a motor vehicle accident that resulted in fractures of the right ankle, right wrist and left clavicle that required operative intervention. The surgeries were successful with no documented complications. The records also document that the patient's post-operative pain was well controlled, and his lab values and vital signs were within normal limits after surgery. There were no signs of post-operative infection or excessive post-operative bleeding. Thus, based upon the documentation in the records, the inpatient hospital admission was not medically necessary.
The current, peer-reviewed literature, including a recent article published by Qin and colleagues in the Journal of Bone and Joint Surgery in 2016 concluded that In patients with closed fractures and minimal comorbidities, outpatient open reduction internal fixation (ORIF) was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients." Another article published by Whiting and colleagues in the Journal of Wrist Surgery in 2017 concluded that "Inpatient operative treatment of distal radius fractures is associated with significantly increased rates of major and total complications compared with operative treatment as an outpatient. Odds of a major complication are six times higher, and odds of total complications are two and a half times higher following inpatient distal radius ORIF compared with outpatient. Quality improvement measures should be specifically targeted to patients undergoing distal radius fracture ORIF in the inpatient setting." Based upon the conclusions of these peer-reviewed studies, the inpatient hospital stay for the management of these fractures was not medically necessary. This determination is based upon the documentation in the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature.