Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Slipped capital femoral epiphysis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a teenage male. The denial is for inpatient admission to the hospital. It was denied as not medically necessary. It states the patient does not meet clinical criteria. A review of the records shows that the patient could have been placed in observation under monitoring. There is an appeal letter that states the patient presented to the hospital as a transfer from an outside facility to receive a high level of care. He 
presented to the outside facility due to the inability to bear weight on the right leg. He was diagnosed with a slipped capital femoral epiphysis of the right leg at the outside institution. On the date of admission, the patient underwent surgery for his slipped capital femoral epiphysis. There were no documented complications with the procedure. He had an ultrasound postoperatively that was negative for deep vein thrombosis (DVT). He was made non-weight-bearing on the right lower extremity postoperatively. Physical therapy (PT) and occupational therapy (OT) were ordered. The discharge summary states the patient's pain was controlled throughout the admission. He was to work with physical therapy (PT) and occupational therapy (OT) postoperatively. Pediatric consult note stated the patient transferred for surgical mallet management of a slipped capital femoral epiphysis. He had an inability to bear weight on the right lower extremity after the fall. Orthopedic consultation stated the pain was well controlled. X-ray showed an unstable slipped capital femoral epiphysis. Surgery was recommended. A pediatric consult progress note on postoperative day 1 stated there were no acute events overnight. Vital signs were stable. Pain was well controlled. The operative note stated the patient underwent a right hip percutaneous pinning. He was transferred to the recovery room in stable condition. Orthopedic progress note stated the patient was lying comfortably in bed. Orthopedic surgery postoperative check noted pain was well controlled. Orthopedic progress note from postoperative day 1 stated the patient is lying comfortably in bed. Pain was well controlled and 
vital signs are stable. Orthopedic progress note postoperative day 2 stated pain was well controlled and vital signs was stable.

The proposed treatment was not medically necessary.

Based on the records provided, there is no documentation that the patient's medical condition, safety, or health would have been significantly and directly threatened if care had been provided 
in a less intensive setting. There is no documentation of a postoperative complication, cardiac arrest, hypoxia, uncontrolled pain, infection, or other factors necessitating an inpatient level of 
care. The inpatient admission was not clinically appropriate in terms of its type, frequency, extent, site, and duration and considered effective for the patient's injury and pathology. There is nothing in the documentation to suggest the inpatient admission was mainly for the convenience of the doctor or other healthcare provider.