Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Ankle Fracture
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with a complaint of right ankle pain after a fall on a broken staircase. She initially was treated for a right ankle fracture dislocation with reduction and placement of an ankle splint. Upon outpatient follow up, the ankle was noted to be persistently dislocated. The patient was then admitted to the hospital for surgery. An external fixator was placed for temporary stabilization of the unstable ankle fracture.

The patient remained in the hospital until she was brought back to the operating room for removal of the external fixator and definitive open reduction and internal fixation (ORIF) of the right ankle fracture. This surgery was completed without any documented complications. The patient was admitted to the hospital after this second ankle operation and was eventually discharged to a rehabilitation center. 

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment, and in the best interest of the patient in this case. This determination is based upon the provided records and the recommendations of the current, peer-reviewed literature.

The requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient. The records document that this patient was admitted for inpatient status after undergoing placement of an external fixator for a fracture dislocation of her right ankle. The provided records contain no specific documentation that justifies the patient remaining in the hospital until definitive ankle fracture fixation was completed.

This patient could have been safely discharged, then returned for the second stage of the operation to be completed on an outpatient basis. This process is supported by the peer-reviewed literature based on the articles published by Malik and colleagues in the Journal of Foot and Ankle Surgery in 2020 and by Qin and his co-authors in the Journal of Bone and Joint Surgery in 2016. Malik and colleagues concluded that "After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3 percent (%) versus 4.0%), myocardial infarction (0.9% versus 1.8%), acute renal failure (2.2% versus 5.3%), urinary tract infections (7.4% versus 12.3%), and pressure ulcers (0.9% versus 2.0%). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%) and emergency department visits (13.8% versus 16.2%)." Qin and associates concluded that "In patients with closed fractures and minimal comorbidities, outpatient 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." Thus, based on the documentation in the records and the recommendations of these peer-reviewed articles, the inpatient hospital admission in this case was not medically necessary. 
 
The health plan's determination of medical necessity is upheld in whole.