Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Open displaced comminuted left tibial fracture
Treatment: Inpatient admission 
The insurer denied: Inpatient admission 
The denial is overturned

The patient is an adult male. He presented to the emergency department with a referral for orthopedic evaluation. Admission was undertaken for surgical procedure, open displaced comminuted left tibial fracture that had been repaired nine months earlier. Open reduction total fixation was to be undertaken. Fracture reduction was complicated by delayed wound healing with persistent drainage. Treatment had been provided through an outpatient setting for which there was noted the persistent drainage over the left medial ankle region for one month's time. On admission it was appreciable that drainage and tenderness was noted over the area of the tibial shaft. Surgical treatment had included removal of hardware from the left ankle, irrigation debridement, wound cultures. It was noted that wound cultures grew out Enterobacter. A PICC (peripherally inserted central catheter) line was put in place with infectious disease recommendation for IV (intravenous) Ertapenem. An appeal letter from the hospital noted that this individual had sustained a type III open tibia fracture. The treatment had included irrigation, debridement of the left tibia with wound VAC (vacuum-assisted closure) put in place. Intramedullary nailing, irrigation debridement ORIF (open reduction internal fixation) left ankle with syndesmotic repair ORIF (open reduction internal fixation) left tibial plateau and left fibula was undertaken.

In the review of the progress notes on the date of admission there is noted to be drainage over the left medial ankle for over one month's time. Local wound care had been undertaken. Indication for left ankle irrigation debridement and removal of hardware was recommended. This was then undertaken. Broad-spectrum antibiotics were initially started with vancomycin, piperacillin tazobactam. The following day the postoperative pain was appreciable but the patient was found to be stable. Infectious disease has been consulted. DVT (deep venous thrombosis) prophylaxis was monitored. Postoperative course was reported to be progressing as expected. The cultures had grown out Enterobacter with susceptibilities noted. Subsequently it was decided to change antibiotics from vancomycin and piperacillin, tazobactam to ertapenem. PICC (peripherally inserted central catheter) line had been recommended with the duration of treatment for six to eight weeks time. The PICC (peripherally inserted central catheter) line was performed with discharge to home infusion for IV (intravenous) antibiotics.

Within the appeal it was detailed by the reviewing physician that given the cultures, placement of wound VAC (vacuum-assisted closure), PICC (peripherally inserted central catheter) line and the arrangement of home infusion that the delayed discharge was reasonable because of the severe illness, the intensity of resources needed, and the medical necessity for length of stay was consistent with the inpatient setting.

The inpatient admission requested was medically necessary.
The medical treatment that was undertaken included debridement of an infected ankle status post open ankle fracture, fixation. The ankle was infected for which outpatient treatment had failed. It was necessary to remove the hardware. With debridement, cultures were obtained. Enterobacter grew out, for which once identified a PICC (peripherally inserted central catheter) line was put in place. All of the treatment was medically necessary for long-term antibiotics, intravenous for which the PICC (peripherally inserted central catheter) line was necessary. Discharge was prolonged secondary to the delayed treatment and providing the resources for PICC (peripherally inserted central catheter) line, determining the correct antibiotic given the sensitivities identified.