Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Bone Fracture/Break.
Treatment: Inpatient stay.
The health plan denied the inpatient stay as not medically necessary.
The reviewer has overturned in whole the health plan determination.

This is a patient who sustained a mechanical fall downstairs at home. The patient presented to the emergency department and x-rays confirmed the presence of a right tibial shaft and fibular fracture. The provider noted that the pulses could only be obtained by Doppler. Sedation was given and a closed manipulation and casting was performed, and surgical stabilization was advised. The patient was monitored for compartment syndrome and she ultimately underwent intramedullary nailing of the right tibia/fibula and posterior malleolar percutaneous fixation. By the next day she was deemed stable and was cleared for discharge.

The clinical notes document evaluation of the right lower extremity. The patient denied numbness or tingling. Objectively, there was varus deformity of the mid shaft tibia with medial ecchymosis, and soft and compressible compartments. The plan was to inspect the leg over the next 12-24 hours and if there are no major inflammatory responses, they will proceed with surgery. There is note of serous blisters on the medial aspect of the leg at the level of the fracture, palpable pulses and 4/10 pain. The plan was to postpone surgery until the soft tissue envelope improves. It is noted that the pain was controlled with medications. The compartments remain soft and compressible. There is note of significant skin fracture blisters. The patient underwent a closed right tibial shaft and fibular fracture reduction, and they were placed in a bivalve lower leg cast.

There is an inherent risk for compartment syndrome with a tibia and fibula shaft fracture. After a closed reduction, the patient was monitored for compartment syndrome prior to proceeding with surgical fixation. Allowing for the surrounding soft tissue condition to improve and monitoring for development of compartment syndrome is appropriate and standard of care with this type of fracture.

The article cited below from the BioMed Central (BMC) musculoskeletal disorders Journal states that acute compartment syndrome developed in 11.4% of tibial shaft fracture cases. The Merck manual, cited below, states that compartment syndrome must be diagnosed, and treatment started, before pallor or pulselessness develops, indicating necrosis. The article cited below from the Journal of the American Academy of orthopedic surgeons concluded that compartment syndrome has been associated with fractures of the tibial plateau, shaft, and plafond. In this case, the patient was diagnosed with a closed right tibial shaft and fibular fracture following a fall downstairs. The fractures were reduced, and a bivalve long leg cast was applied to allow for frequent monitoring for the potential development of compartment syndrome. They were admitted to the orthopedic service for surgical intervention which is ultimately performed. Given the inherent risk of compartment syndrome and the need for prompt intervention if it should develop the inpatient stay was medically necessary in this case.