Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic osteomyelitis.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is modified.

This is a male patient with a medical history of traumatic open pilon fracture of the left tibia/fibula and right distal radius following a fall from a ladder, status post fixation of wrist and left distal tibia.  The patient presented with left ankle edema and drainage from the distal tibia wires, and had been taking ciprofloxacin for 12 days.  The patient was evaluated in the orthopedic clinic and underwent left ankle aspiration that yielded Staphylococcus intermedius.  The patient was admitted for planned procedure of the left ankle (incision and drainage) and external fixator removal and pre-operative medical evaluation for displaced pilon fracture of left tibia.  Per a brief operative note on day 2 of admission, the patient underwent removal of external fixator, lower extremity, with incision and drainage, post-operative wound infection of the lower extremity for the pre-operative diagnosis of displaced pilon fracture of the left tibia.  The patient tolerated the procedure with no complications and was noted as stable on transfer to recovery.  The post-operative course included intravenous (IV) Ancef, per infectious diseases recommendation.  The patient was ambulating with physical therapy on days 3 to day 5 of admission and was cleared for discharge home on IV antibiotics on day 6 of admission with orthopedic follow-up.

The patient's medical record demonstrates that this patient presented with a complex and unique condition.  The patient has chronic osteomyelitis to his distal tibia and had undergone several procedures.  The patient's operation was complex and extensive.  The patient's physician detailed the intraoperative findings of dead space and nonunion.  The patient's physician placed antibiotic beads and a drain.  The post-surgical course was complicated by continued drainage (albeit slight).  The drain was not removed until day 5 of admission.  It was important to monitor his wound, as the risk of complication for poor healing was high.  Appropriate monitoring could not be provided at a lower level of care.  The patient also required patient controlled analgesia (PCA) for several days.  This intensive level of pain management modality would also not have been able to be obtained at a lower level of care.  The patient also required infectious disease consultation on more than one occasion in order to establish the definitive infectious organism to provide the right antibiotic for this patient.  A peripherally inserted central catheter (PICC) line was also medically necessary as a requirement for this patient's long-term antibiotic treatment.  Given this level of intensive care needs postoperatively, the inpatient admission was medically necessary for this patient from days 2 to 6 of admission.  However, there was no indication for admission on day 1 of admission.

The health plan acted reasonably with sound medical judgment to deny coverage for day 1 of admission but did not act in the best interest of the patient to deny coverage from days 2 to 6 of admission. 

The medical necessity for the inpatient hospital admission is partially substantiated.  The insurer's denial should be modified.  Deny day 1 of admission. Approve days 2 to 6 of admission.