Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital bowing of the left tibia and fibula.
Treatment: Hospital admission inpatient.

The insurer denied coverage for hospital admission inpatient.
The denial is overturned.

This case involves a male who was admitted to the hospital for surgery with a diagnosis of congenital bowing of the left tibia and fibula, a cyst of the bone in the left lower leg, neuropathy of the left lower limb, nontraumatic compartment syndrome of the left lower extremity, and an acquired left tibial deformity.  He underwent surgery consisting of osteoplasty of the left tibia fibula, insertion of a prophylactic intermedullary nail and screws of the left tibia, prophylactic common peroneal nerve release and prophylactic fasciotomy of the left anterior compartment.  According to the records, the surgery was completed without complications.  Postoperatively, the patient received 24 hours of prophylactic antibiotics and was treated with Ecotrin for deep vein thrombosis prophylactically.  His pain was managed by acute pain services with intravenous patient-controlled analgesia pump.  He was subsequently transitioned to oral medications and underwent compartment checks every 48 hours with no signs of compartment syndrome.  He tolerated physical therapy and achieved all necessary goals for discharge.  The patient was discharged.  He previously received a notice of adverse determination regarding hospital admission for inpatient services.  It was determined there were no complications following surgery and the patient should have been able to go home within a short period of time.  

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

A hospital admission and inpatient site of service is considered medically necessary for this patient.

Literature has noted that the goal for inpatient stay for patients undergoing a tibial osteotomy procedure is ambulatory one day postoperative.  However, extended stays may be prolonged for more than 7 days depending upon the extent of surgery as well as the patient's medical history and in taking the patient's age into consideration. The patient underwent osteoplasty of the left tibia fibula, insertion of a prophylactic intermedullary nail and screws of the left tibia, prophylactic common peroneal nerve release and prophylactic fasciotomy of the left anterior compartment, which increased the patient's risk of deep vein thrombosis and pulmonary embolism following surgery.  The procedure is also considered exceedingly painful and often requires various pain-relieving measures in the postoperative setting.  While the information noted that the patient was doing well postoperatively, with no evidence of complications at the 24-hour mark, continued inpatient stay for additional days would be standard of care given the complex procedure and potential for postoperative complications. 

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 a hospital admission inpatient site of service is overturned. Medical Necessity is substantiated.