Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthritis.

Treatment: Inpatient admission.
 
The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient who presented to the hospital for an elective triple arthrodesis of the left foot. The patient underwent the procedure under general anesthesia and was admitted to the hospital post operatively for uncontrolled pain. A well-padded bi-valved fiberglass cast was applied to the patient's left lower leg. The records showed that the patient's baseline vitals taken at 8 am on day of admission were: temperature 36.4 C, heart rate 85, respiration 17 and blood pressure 157/94. The patient's pain management consisted of Percocet 5/325 mg orally, every 4-6 hour as needed for pain severity 7-10, Ibuprofen 600 mg orally, every 4-6 as needed for pain severity 4-6, and Tylenol 650 mg orally as needed for pain severity 1-3.The patient's pain screen for transfer to floor stated "no pain now" and "no ongoing problem with pain." The following day patient's cast had to be removed strikethrough bleeding or for evaluation of pain, which is standard of care if there was any concern for pain post operatively. The patient was transferred to a rehabilitation facility. 

Based on the review of the medical record, the patient did not require any intravenous (IV) pain medication throughout her inpatient stay. The note from the initial physical therapy (PT) evaluation reported the patient's pain as 4 out of 10, in severity. However, given the patient's inability to perform all functions, it was recommended that she be transferred to subacute rehab.  On POD #2, the patient's cast had to be changed only because it had gotten wet from the ice behind her knee; there was no mention of any other intervention from Podiatry. The patient was finally discharged to rehabilitation facility per the case management notes, although the patient verbalized adequate pain control.  The note from the Podiatry team on POD #3 continued to reveal no need for intervention while the patient was hospitalized. 

Based on the review of the medical record, this patient had a completely unremarkable post-operative course at the hospital requiring no need for intravenous pain medication and no need for any other intervention for pain control from the Podiatric team.  The patient's vital signs were even improved from her pre-operative baseline values. The American College of Foot and Ankle Surgeons agrees on the consensus that "a multimodal approach to postoperative pain management"1 should be considered for all surgeries of the foot and ankle. In this case, this was not even necessary as the patient's oral pain medications and anti-inflammatories were working well for the patient. Furthermore, studies support that a number of analgesic techniques simultaneously can provide for a synergistic effect that can be more effective post operatively. These techniques include but are not limited to peripheral nerve blocks, alpha-2-delta ligands and long term agents with regional anesthesia, none of which was needed to be provided for this patient post operatively.1 

Given that there was no need for any intervention for post-operative pain control other than for this patient's oral pain medication, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.