Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Finger amputation
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a male. He was noted to have sustained an injury that was related to a crush injury in a door with the need for a finger amputation. His noted comorbidities included schizophrenia and bipolar disorder.

Surgery was undertaken, removing part of the finger without complications. The hospital appeal letter described an individual with schizophrenic bipolar disease who presented to the emergency department with severe progressive worsening right middle finger digit pain new onset of discoloration secondary to traumatic crush injury secondary to catching his finger in a door. He had been hospitalized previously for the injury. He had an acute comminuted displaced fracture for which over reduction internal fixation cannot be undertaken due to limited operating resources. Orthopedic Surgery was consulted at the time. Acute inpatient care was recommended because of severe progressive worsening of the right middle finger pain and discoloration. IV (intravenous) antibiotics were provided with the need for definitive surgical intervention. Surgery was undertaken for right distal third digit amputation.

Once clinically stabilized, it was felt that the patient could be discharged in accordance with the Millman care guidelines. It was felt that due to the severity of presenting symptoms and high-risk for complications, close inpatient monitoring was recommended for the digital amputation. It was felt that this cannot be undertaken on an outpatient basis.

The emergency department record noted area of darkening and skin necrosis over the last of the right third digit sutures were in the digit itself distal right third digit. Surgery had been undertaken for the crush injury. He was admitted for surgery. The patient was noted to have history of bipolar disorder with necrosis of the right distal third digit with a comminuted displaced fracture. Surgery, ORIF (open reduction internal fixation) had been at the time secondary to limited Covid 19 (Coronavirus 2019) resources. Washout with laceration repair was done in the clinic. Healing was progressing until three days prior, with discoloration. The pain became problematic.

The patient was made nothing by mouth and given IV fluids for which surgery was recommended, with amputation. Noted under surgical pathology was the findings of necrotic right distal phalanx. The operative procedure was noted to include amputation of necrotic tissue proximal to the DIP (distal interphalangeal) joint, skin debrided and closed.

Yes, the inpatient hospital admission was medically necessary.

The inpatient hospital admission was medical medically necessary given the issues associated with necrotic tissue as related to the crush injury of the digit. Noted is that this individual had undergone a closure of the wound after crush injury, but could not undergo surgery because of problems associated with limited resources secondary to the Covid 19 pandemic.

In the consideration for amputation, the ODG (Official Disability Guidelines) guidelines were considered, stating the following in regards to amputation: "For chronic ischemia, amputation becomes an option when other re-vascularization efforts fail. Many traumatic fingertip amputations are best treated with initial irrigation and debridement followed by secondary intention wound closure. Revision finger amputation is acceptable for more complex injuries, allowing earlier return to work than replantation, which should be more strongly considered for the thumb and loss of multiple fingers."

The records clearly indicate that there was a degree of necrosis present, for which the surgical intervention was undertaken. As noted under Green's Operative Hand Surgery, under infections in the digits, it states the following: "When humoral and cellular immunity are impaired, it is critical that three important components of treatment be implemented: antibiotics, surgical debridement of the infected tissue, and increased immunity through improved nutrition. Poor nutrition, whether from alcoholism, cancer, major trauma, or inadequate diet, predisposes the patient to infections and poor wound healing that would otherwise be easily combated by healthy individuals." Notable, therefore, was that the importance of undergoing the amputation. The comorbidities involving schizophrenia and bipolar leads to the necessity for monitoring the condition to ensure that the individual is stable prior to discharge as was notable within the documents reviewed. Therefore, the treatment provided was medically necessary along with the in hospital stay in order to ensure stabilization of the condition. Particularly given the comorbidities present, the compliance can be compensated, for which the overnight stay rather than outpatient was considered reasonable. Therefore, the inpatient hospital admission was medically reasonable for the treatment of this individual's condition.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

In the consideration of the Millman Care Guidelines, the treatment for inpatient hospital admission can be indicated for an individual with "Newly diagnosed or suspected bone, joint, or orthopedic device infection (eg, osteomyelitis, septic arthritis) that requires 1 or more of the following (1)(2)(3):

1) IV [intravenous] antibiotics that cannot be initiated in other than inpatient setting (eg, patient too unstable or home infusion not available) 2) Device removal or replacement 3) Joint drainage (drain placement or repetitive aspirations) 4) Bone or soft tissue debridement."

Noted is that given that treatment had been delayed secondary to Covid 19 limitations in regards to resources, the issues associated with necrosis and infection were present, and septic arthritis, which required the degree of inpatient overnight stay. Also given the comorbidities that were notable as stated because of compliance issues, it was reasonable to provide the overnight stay for stabilization to ensure that no complications arose secondary to the surgical procedure for which the services provided were medically reasonable for the treatment of this individual's condition.