Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic Knee Injury
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient sustained a traumatic injury to the bilateral knees. The emergency department clinical note states that the patient presented for treatment of bilateral tibia fractures and a right fibular head fracture status post a bicycle accident. The patient was transferred from another hospital for a higher level of care. The patient was wearing a helmet and denied loss of consciousness or head trauma. The computed tomography (CT) scan of the left knee revealed an acute left tibial plateau fracture with depression consistent with a Schatzker type II fracture. The CT scan of the right knee showed multiple fractures involving the proximal tibia at the level of the medial tibial plateau, lateral tibial plateau, and an oblique fracture of the posterior and anterior cortex of the upper one third of the tibia, spiral oblique type consistent with a Schatzker type VI fracture. The x-ray of the right knee also revealed a right fibular head fracture. The plan was to follow orthopedic recommendations with anticipated admission for surgical intervention.
A clinical note  states that the patient will require operative fixation of bilateral tibial plateau fractures when soft tissues allow. The plan was to continue with compartment checks every 4 hours and initiate Lovenox.
There is an operative report stating that open reduction and internal fixation of a bicondylar tibial plateau fracture on the right side was performed as well as a right lateral meniscal repair. The left side was examined under anesthesia and recommended for conservative management.
The postoperative orthopedic progress note states that there were no acute events and the pain was controlled. The medication list included intravenous (IV) Dilaudid and oral Oxycodone. The vital signs were stable. The patient was nonweightbearing in knee braces. The plan included physical/occupational therapy, continuation of Lovenox for deep vein thrombosis (DVT) prophylaxis, and pain control.
The progress notes state that the pain remained controlled with medications. There were no acute clinical events. The patient was cleared to initiate passive range of motion of bilateral knees with unlocked braces. The patient was to be discharged on Lovenox for 4 weeks and to maintain a nonweightbearing status.
The patient required IV pain medication followed by transitioning to a by mouth (PO) pain management regimen. The pain was noted to be controlled on the oral regimen and the patient was discharged to a skilled acute rehabilitation facility.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary. The Official Disability Guidelines (ODG) were referenced as specific recommendations are made regarding hospital length of stay following specific procedures. The ODG supports 3 days as the best practice target for hospital length of stay following open reduction and internal fixation of a tibia fracture when there are no complications. In this case, the patient underwent open reduction internal fixation of a complex right tibial plateau fracture. The patient also sustained a left tibial plateau fracture which was treated nonoperatively. The postoperative pain management required IV Dilaudid  when they were transitioned to an oral regimen. The continued inpatient stay was noted to be required due to the need for IV analgesics. The patient was deemed stable on the oral regimen for discharge to a skilled acute rehabilitation facility. Given the presence of multiple injuries and the need for IV analgesics postoperatively, the continued inpatient level of care was appropriate to avoid the need for readmission for pain management. Based on the available information, the requested health service/treatment of inpatient stay was medically necessary for this patient.