Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status/post) Vehicle Accident
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with a history of substance abuse (heroin and cocaine) currently taking methadone. The patient suffers from hepatitis C. The patient presented to the hospital with left leg pain, swelling, and deformity after being struck by an automobile while riding a Moped. 

The patient's vital signs on arrival were normal. The patient was diagnosed with a non-displaced closed left distal tibia fracture. No other injuries were identified. The fracture was splinted by the Paramedics and then re-splinted by Orthopedic Surgery. Post-splinting x-ray showed a comminuted slightly displaced fracture of the left distal tibia. The patient was admitted to acute inpatient level of care. Admission orders included nothing by mouth, intravenous fluids, intravenous analgesia medication, and intravenous antibiotics. Plans on admission were for the Operating Room the following day to rod the fracture.

The patient underwent closed reduction and intramedullary nailing of the left tibia. The procedure went well without complications. Postoperative orders included intravenous antibiotics, pain control, and physical therapy. The patient was non-weight bearing on the affected extremity. Postoperative plan were rehab, venous thromboembolism prophylaxis, labs, and discharge planning.

Progress Note day three, states patient was doing well. 24 hours of antibiotics postoperative were ordered. A walker was requested.

Progress Note on day four states the patient was doing well. The plan was to discharge when cleared by Physical Therapy.

The patient was not evaluated by Physical Therapy until day five. The patient was able to ambulate short distances but tired easily. The patient required hands-on steadying assistance. The patient required further gait and stair training prior to discharge.

Progress Note day six states discharge planning when cleared by Physical Therapy. Physical Therapy note states patient needs assistance with stairs and transfer, which her husband can provide.

Day six, the patient was deemed fit for discharge and was discharged that day.

Coverage for the acute inpatient level of care was denied by the health plan as not medically necessary. The hospital through its agent has appealed the denial of the acute inpatient admission stating that admission was deemed medically necessary and in the best interests of the patient until the date of discharge. A physician notes, "any lower level of care would be considered imprudent and dangerous."

No, the Inpatient admission was not medically necessary. The information available at the time the decision for admission was entered did not warrant an acute inpatient level of care.
The patient is a female that sustained a fracture of the left tibia after being struck by an automobile while on a scooter. The fracture was closed and minimally displaced. The patient had normal vital signs and normal labs. The patient underwent evaluation in the ER (emergency room), which demonstrated no other injuries. Orthopedic Surgery splinted the leg and scheduled surgery the following day. The patient underwent closed reduction and intramedullary rodding the following afternoon, more than 24 hours after the decision for surgery had been made. Postoperatively, the patient was to be non-weight bearing on the affected leg. Postoperative orders included intravenous antibiotics for 24 hours, pain control, and physical therapy. Physical therapy did not see the patient until postoperative day # 2 resulting in a delay in ambulation and clearance for discharge. Physical therapy determined the patient required further gait and stair training prior to discharge in their note. Therefore, the preoperative day and the delay in physical therapy resulted in additional hospital days.

MCG (Milliman care guidelines) Health guidelines note the goal for length of stay is ambulatory or 2 days postoperative. The 2 days postoperative is consistent with that which is available at a lower level of care than acute inpatient. The guidelines state most closed reductions are treated on an ambulatory basis. Some simple closed fractures requiring open reduction in nonelderly (younger than 65 years) patients who do not require inpatient monitoring or treatment may be treated on an ambulatory basis. Patients undergoing open reduction, and patients with open fractures, complex (e.g., comminuted) fractures, multiple fractures, or who require prolonged (e.g., more than 24 hours) inpatient monitoring or treatment (e.g., for compartment syndrome, other injuries, unstable comorbidities) are treated on an inpatient basis. None of these situations apply.

The care rendered was amenable to a lower level of care but for the delays in operative treatment and postoperative physical therapy. The care the patient would have received at a lower level of care would have been identical to that which she in fact received.

Yes, the health plan acted reasonably, with sound medical judgment and without compromise of the best interest of the patient in the denial of the acute inpatient level of care admission. The patient could have been treated at a lower level of care without compromise of patient safety or the quality of care rendered.
The patient is a female that a closed fracture of the left leg. The patient arrived at the hospital as a Level 2 trauma. She was hemodynamically stable. She underwent multiple imaging studies which did not demonstrate any other injuries. Orthopedic Surgery determined the patient required internal fixation which was deferred until the following day. The patient was admitted to acute inpatient level of care. The patient underwent closed reduction and intramedullary rodding the following day. The care the patient received could have been at a lower level of care such as observation level of care.

The anticipated length of stay should have been no more than 2 past-midnight stays from information available at the time the decision to admit was made. The patient was admitted and evaluated and decision for surgery was made. The patient could have undergone the operative procedure that day. Physical therapy should have been done the next day after surgery. Acute inpatient level of care is not the appropriate level of care for this diagnosis or this patient's care. It is in excess of the level of care which is necessary to provide safe treatment.

Regarding the hospital's appeal that admission was necessary because, "any lower level of care would be considered imprudent and dangerous," is not accurate. No reason is given why the care rendered could not have been at a lower level of care. The care the patient would have received at a lower level of care would have been identical to that which he in fact received without compromise of the quality of care rendered or patient safety.