Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankle Fracture
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was diagnosed with a right closed bimalleolar equivalent ankle fracture. A clinical note states that the patient fell several weeks prior to presentation while dancing and sustained a right ankle fracture and right knee dislocation. The patient presented to the emergency department at the request of orthopedics to be admitted for surgery. There is no pertinent surgical or past medical history. The patient was in a long leg splint with a knee immobilizer. On examination, the patient was in no distress. There was a small right knee effusion; however, an unremarkable knee examination overall. There was tenderness to palpation at the ankle and the compartments were soft and compressible. The x-rays were noted to show a right Weber B fibula fracture with associated medial clear space widening, consistent with a bimalleolar equivalent ankle fracture. The patient underwent open reduction internal fixation of the right ankle fracture.
The postoperative note states that the pain was well-controlled and there were no adverse clinical events overnight. The patient tolerated the procedure well and was discharged on Lovenox and with home services. A letter of medical necessity stated that the patient had intractable pain despite being on oral analgesics which prompted the patient to come to the emergency department for evaluation and treatment of pain and that the patient required the acute inpatient level of care for the management of the right ankle fracture with evidence of malunion.
At issue is the medical necessity of the inpatient stay.

The inpatient stay was not medically necessary. In this case, the patient was diagnosed with a right Weber B fibula fracture with associated medial clear space widening, consistent with a bimalleolar equivalent fracture. The patient presented to the emergency department at the request of the orthopedic specialist. The patient was noted to be in no acute distress upon presentation. The patient underwent open reduction internal fixation and tolerated the procedure well. There were no documented comorbidities or conditions that would preclude safe treatment in the outpatient setting in this case. 
The article cited below from the orthopedic clinics of North America states that in properly selected patients, outpatient open reduction internal fixation has been shown to be comparably safe. The article cited below from the Foot and Ankle international Journal states that routine perioperative admission of those with ankle fractures is a financial burden and ankle fractures, including bimalleolar fractures, can be safely and effectively treated on an outpatient basis. The article cited below from the Journal of Bone and Joint Surgery concluded that in those with closed fractures and minimal comorbidities, outpatient open reduction internal fixation was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. In consideration of the available information, the inpatient was not medically necessary for this patient.