Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left ankle pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for a left femur fracture, morbid obesity, obstructive sleep apnea, anxiety, and a recent right ankle fracture. She presented to the emergency department with complaints of left ankle pain. The patient stated that she was getting out of bed to go to the bathroom and fell onto the left ankle and left arm. She denied any head injury or loss of consciousness. The patient reported bruising of the left arm. Following the fall, she was unable to bear weight on the left ankle.
The review of systems was negative for chest pain, nausea, vomiting, fever, chills, shortness of breath, cough.

When seen by the admitting physician, the patient was afebrile. Her blood pressure was 116/82, pulse rate 94 beats per minute (bpm), respiratory rate 18 breaths/minute, and oxygen saturation 99% on room air. The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi.

There was swelling and tenderness in the right leg, which was in a short leg cast. The exam of the left ankle showed Achilles tenderness with no obvious palpable defects.

There was a pain to palpation in the lateral aspect of the left ankle. The patient had normal distal peripheral pulses. The left lateral shoulder had a 3 centimeter (cm) bruise. There were no limitations in the range of motion. The patient was admitted to the hospital because of an inability to ambulate.

In the hospital, the patient was seen by an orthopedic surgeon who suggested that the patient had a second-degree left ankle sprain, as well as a healing right ankle fracture. The patient was placed in a walker boot. The orthopedic surgeon recommended weight-bearing as tolerated to the left lower extremity while the foot is in the walker boot, and pain control.

In the hospital, the patient worked with physical and occupational therapy. At the end of the hospitalization, the patient was discharged home with a wheelchair and commode.

At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

The review of the medical records demonstrated that the patient presented to the hospital with a left ankle injury that was described as a second-degree left ankle sprain. The treatment of second-degree ankle sprains includes immobilization of the ankle in a neutral position with a posterior splint or a commercially available boot, followed by mobilization and physical therapy.

There was no evidence that this injury was associated with bone, joint, or muscle infection. There was no evidence of left ankle fracture, dislocation requiring surgical intervention, or any other condition that would necessitate admission at the acute inpatient level of care.

There was no mention that the patient's ankle injury was associated with compartment syndrome, other major injuries requiring inpatient stabilization, limb-threatening injury, or severe pain that would necessitate frequent administration of intravenous pain medications. There was no evidence that the patient had injury associated was rhabdomyolysis.

Taking into consideration all of this information, there was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.