Appeal type: Medical necessity
Decision: Overturned

Diagnosis: S/P (status post) Accident.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She sustained an injury for the right arm while riding an ATV (all terrain vehicle). She had sustained the injury with a fall with an injury to the right arm the day before she presented to the emergency room. Noted was that she presented with her mother after falling the day before with swelling and pain was present into the elbow. She was initially seen in an outpatient setting and referred to the emergency room for further assessment of the condition.

X-rays were obtained showing evidence of a displaced supracondylar fracture. Emergency department assessment was undertaken there was found the displaced fracture was present. X-ray imaging demonstrated the distal humeral fracture. Orthopedic consultation was undertaken. No medical comorbidities noted other than asthma. With the displaced fracture appreciable surgical intervention was recommended. With surgery undertaken on the day of admission she was kept overnight, notable that surgery was undertaken. 

The patient was found to be stable from a neurologic basis. Attending assessment  noted clinical exam with the patient able to wiggle fingers sensation intact neurologic function intact. The condition was felt to be stable for she can be discharged to home with orthopedic follow-up. She was then discharged to home.

Coverage of the overnight stay was denied by the health plan as not medically necessary. An appeal letter from Montefiore Hospital detailed the risks involved and therefore given the issues was felt to be reasonable for the overnight extended stay.

Yes, the Inpatient Hospital Admission was medically necessary.

This patient presented to the emergency department for which after assessment surgery was recommended. The young girl was left nothing by mouth so surgery can be undertaken with the anesthesia record indicating that surgery was initiated. A closed reduction with pinning of the supracondylar fracture was undertaken. The patient was then kept overnight for neurologic evaluation.

Notable is the ODG (Official Disability Guidelines) guidelines provide some insight into the aspect of hospital length of stay. For a fractured extremity, arm the best practice is described the following: "Closed Broken Arm, IF (ICD 79.11 - Closed reduction of fracture with internal fixation, humerus)

With this type of supracondylar fracture, there is always a concern given the displaced aspect of the supracondylar fracture of nerve and/or vascular embarrassment. The overnight stay would be supported by these guidelines as medically reasonable. Particularly given that surgery ended in the middle part of the evening it is necessary to monitor the condition in order to ensure that there is no significant vascular embarrassment that may require an emergent return to the operating room. Discharging this individual that was still under some aspects of anesthesia, at this age is not medically reasonable. Having a nonmedical person such as this young girl's mother moderate to the condition would not have been reasonable.

This is particularly noted within Morrey's The elbow and its Disorders under complications for supracondylar fracture for which it states the following: "After reduction of the fracture and stabilization with percutaneous pinning, reevaluation of the neurovascular examination is mandatory. On rare occasions, the compromised nerve may recover before the patient's discharge, but in most cases, the neurapraxia requires observation and will gradually return over the ensuing months. If after 4 to 6 months no return of function is noted, electromyelographic and nerve conduction studies are recommended. Only rarely have cases been reported of permanent nerve deficits requiring later neurolysis, grafting, or tendon transfer. Nearly all nerves will return to normal function within the first 6 months following the injury."

Certainly is noted it indicates that neurovascular examination is "mandatory." Therefore this Requires observation For which the overnight stay, discharged was medically appropriate for this young patient's condition. Therefore the treatment that was provided was medically appropriate and in accordance with reasonable medical assessment and follow through with standards of treatment.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
A recognized treatise on the treatment of elbow injuries particularly supracondylar type fractures indicates that observation is "mandatory." Therefore for the timeframe that this patient underwent surgery, came out of surgery, observation was mandatory overnight to ensure that there was no evidence of significant neurovascular compromise. She was found to be stable the following day and was reasonable for discharge. Therefore the inpatient admission was medically reasonable for this individual's condition.

Treating the patient at an ambulatory level of care would not have been sufficient for the observation that is necessary to recognize a pending embarrassment to the nerve and vessels. The necessity in this instance for the extended stay was to prevent such complications that can result in a protracted post-operative recovery. Additionally, an unrecognized complication because of a delay in diagnosis can result in permanent dysfunction. This is at best mitigated by the inpatient admission this individual was afforded.