Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right femoral neck fracture
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an elderly male. Per the records, the patient states that he suffered a medical emergency due to a fall on ice while attempting to walk his dog, whereby he struck his right hip against a rock. He sustained a fracture. He was admitted.

Per a letter from the orthopedic surgeon, the patient suffered a medical emergency secondary to a fall on the ice. He developed acute right hip pain and inability to walk. He was transferred to the ER (emergency room). X-ray showed a displaced right femoral neck fracture. Surgery was performed.

The patient's past medical history significant for hypertension, enlarged prostate, hearing aids and left cataract. X-rays upon admission showed a displaced right acute femoral neck fracture.

The patient's H&P (history and physical) is provided. Per the progress note, postoperative day #3 status post right hip hemiarthroplasty: blood pressure stable, vital signs stable. Note states no complications. Pain remains adequately controlled.

On postoperative day #4, there were no acute events. The patient remains afebrile and vital signs are stable.

Per the discharge summary, secondary to the patient's insurance, he was not able to be admitted to the rehabilitation facility.

The health plan denied coverage of the inpatient admission, noting, "Does not appear to meet medical necessity per MCG [Milliman Care Guidelines] guideline called Musculoskeletal Disease (GRG: MG-MD) 25 edition effective 08/19/2021."

The Inpatient Hospital Admission was medically necessary.

The patient had an acute fracture of the femoral neck. He underwent operative repair with a hemiarthroplasty. The patient required physical therapy after the operation. The patient's activity level was not acceptable for the next level of care until the time of discharge. This is reflected in the PT (physical therapy) and OT (occupational therapy) notes provided. The patient meets the MCG (Milliman Care Guidelines) Health General Recovery Guide 25th Edition 08/19/2021.

Per CMS (Center for Medicare and Medicaid Services) Internet-Only Manual (IOM) Benefit Policy Manual, Publication 100-02, Chapter 1, Section 10, "An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will require hospital care that is expected to span at least two midnights and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight."

Per CMS (Center for Medicare and Medicaid Services) (IOM) Program Integrity Manual, Publication 100-08, Chapter 6, Section 6.5.2(A), "Inpatient care, rather than outpatient care, is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting."

Based on the records provided, the patient's safety and medical condition would be significantly and directly threatened if care had been provided in a less intensive setting. The patient had a fracture of the femoral neck. The patient was not able to bear weight. Surgery consisting of a hemiarthroplasty of the hip was required to address this problem. The patient then required skilled physical therapy and occupational therapy to progress in order to be safely discharged from the hospital.