Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fracture, Right leg
Treatment: Inpatient hospital admission

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

This is the case of a patient with a past medical history of attention deficit hyperactivity disorder, alcohol abuse, anxiety, and chronic obstructive pulmonary disorder. He presented to the emergency department (ED) via ambulance post motor vehicle crash while driving his motorcycle. His Glasgow Coma Scale (GCS) score was 15. On exam he had a right, lower leg mid-shaft injury with depression deformity and a 1 x 1 centimeter (cm) oozing laceration on the medial aspect of his calf. Laxity of his lower leg was noted. Pulses distally were palpable and there were no sensory deficits. Imaging noted comminuted fracture of fibula and tibia. The plan included orthopedic consultation, splinting and admission for open reduction internal fixation (ORIF).

Orthopedics indicated the need for urgent incision and drainage (I and D), intramedullary (IM) nail versus external fixation. Trauma Surgical Critical Care evaluated the patient and ordered x-rays of the chest, cervical spine, abdomen /pelvis.  A cervical collar was cleared given no evidence of an acute cervical spine fracture on computed tomography (CT). Medicine was consulted for pre-operative medical clearance. It was noted that patient had moderate risk but otherwise medically optimized for planned procedure. They recommended initiating Clinical Institute Withdrawal Assessment (CIWA) protocol post-operatively.  The patient was taken to the operating room and underwent repair of a right displaced tibia fracture with IM nailing of tibia, irrigation, and debridement of open wound of right lower leg extremity and closure of traumatic wound site. The wound classification was contaminated. The patient had no acute post-operative events; compartment checks were normal overnight.

The patient was doing well the following day. He received intravenous antibiotics, physical therapy, pain control, and disposition planning. Orthopedics noted no acute events on post operative day 2 so he was discharged home with outpatient orthopedic clinic follow up.

According to Milliman Care Guideline (MCG) Health Guidelines Musculoskeletal surgery or procedure notes that the Operative Status Criteria is ambulatory for procedures such as: Closed or open reduction of simple fractures; Simple internal fixations; Simple external fixations; Simple wound repairs; Plastic operations on tendon or joints; Bone biopsies; Removal of most orthopedic devices.  Thus, using these guidelines the patient did require inpatient admission as this was not a simple fracture but rather a comminuted fracture. Thus, he did require care, on an acute inpatient admission status.

In addition, MCG Health Guidelines Tibia/fibula shaft fracture, closed or open reduction notes that most adult and some pediatric patients undergoing open reduction, and patients with open fractures, complex (e.g., comminuted) fractures, multiple fractures, or who require prolonged (e.g., more than 24 hours) inpatient monitoring or treatment (e.g., for compartment syndrome, other injuries, unstable comorbidities) are treated on an inpatient basis. MCG also noted that "Analysis of national hospital discharge data shows 48 percent of hospitalized adult patients undergoing reduction of tibia/fibula fracture discharged in 2 days or less".  Thus, the guidelines indicate for a fracture of this nature that inpatient admission is justified.

Inpatient hospital stay was medically necessary at the acute inpatient level as he could not have been placed on an observation status. Thus, the denial is overturned. 

The health care plan did not act reasonably and with sound medical judgment. 

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.