Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip Osteoarthritis.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This case involves a patient with a request for inpatient admission. The patient was seen at the hospital for right hip pain that has progressively worsened over several years, limited ambulation and activities of daily living (ADLs) and has failed conservative treatment. The patient had a history of severe right hip osteoarthritis and anemia. It was noted that the patient was admitted undergoing a right total hip replacement and was low risk for venous thromboembolism. The patient underwent right total hip arthroplasty with no complications noted. 

The following day, the patient reported adequately controlled pain with a pain level of 0 out of 10 (0/10), no chest pain or shortness of breath. The patient had a blood pressure of 161 over 97 (161/97), temperature of 98.9, heart rate of 71, and oxygen (O2) saturation of 100% (percent). A dressing was in place over the right hip on exam. 

On day # (number) 2, the patient was noted to be doing well and had well controlled pain. The patient was tolerating diet, had no acute complaints, and was out of bed with physical therapy. The patient was afebrile with vital signs within normal limits. On exam, the right hip was tender on palpation with moderately painful range of motion, and the dressing was dry and intact. Sequential compression devices were in place, and mild edema was present on the right calf. Lab work noted a low hematocrit of 33. The treatment plan included physical and occupational therapy with weightbearing as tolerated, out of bed to chair, deep vein thrombosis (DVT) prophylaxis, daily lab work and monitoring of vitals, pain control, as well as iron supplementation for acute blood loss anemia. 

The patient was noted to be doing well on postoperative day 3, with pain well controlled. The patient was noted to be progressing with physical therapy and reported that they had support at home and wanted to be discharged home. On exam, the patient was afebrile with normal vitals. Moderate pain with range of motion and tenderness upon palpation of the right hip was also noted. 

A discharge summary indicated that the patient was admitted undergoing the right total hip arthroplasty, as well as for postoperative pain control, physical therapy, and iron supplementation due to acute blood loss anemia. It was noted that the patient was recovering well and was stable. Lab work noted a low hematocrit of 27. The patient was discharged home with a front wheeled walker, bedside commode, Percocet, ferrous sulfate, docusate sodium, aspirin, celecoxib, acetaminophen, ondansetron, and aluminum hydroxide-magnesium hydroxide-simethicone oral suspension. The treatment plan included continued physical therapy and home exercise. 

Milliman Care Guidelines (MCG) indicates inpatient stay for total hip arthroplasty patients with comorbidities who require more prolonged postoperative treatment or monitoring, such as anemia, with a brief (1-3 days) stay extension when extended inpatient care is needed. Evidence based literature indicates total hip arthroplasty patients have traditionally been managed as inpatients postoperatively. Although the patient was noted to have a history of osteoarthritis of the right hip without acute onset, the records submitted for review indicate that the patient had a history of anemia and acute postoperative anemia, as evidenced by low hematocrit levels during the postoperative phase, that required treatment. As such, the denial is overturned. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient is substantiated.