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201908-120601

2019

Empire BlueCross BlueShield HealthPlus

Medicaid

Orthopedic/ Musculoskeletal

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis: Mild Displaced Communicated Fractures of the distal Tibial and Fibular Diaphysis

Treatment: Inpatient Hospitalization

The insurer denied the Inpatient Hospitalization. The denial was reversed.

This is a male patient who presented to the emergency department (ED) after sustaining a fall on his motorcycle. A left leg x-ray revealed fractures of the distal tibial and fibular diaphysis. A computerized tomography (CT) of his left leg was performed which showed mild displaced comminuted fractures of the distal tibial and fibular diaphysis. There was no compartment syndrome noted. He was evaluated by orthopedics, surgery was recommended. He underwent an intramedullary nailing of his tibial shaft fracture without complications. He was evaluated by physical therapy and occupational therapy. It was determined that he have outpatient occupational therapy. The patient was discharged home safely with follow up instructions.

The medical record demonstrates the patient sustained a traumatic injury that required emergent surgical intervention. His fracture was displaced and required stabilization. This type of injury is prone to swell. There is risk of compartment syndrome. The application of ice and elevation would be required prior to surgery. He would require narcotic analgesia. He was evaluated on a timely basis and surgery was completed the next day. It would not be feasible to splint the extremity and have the man scheduled as a semi-elective procedure. His operation was complex and extensive enough to warrant the post-surgical day.

Based on the above, the medical necessity for the inpatient hospitalization admission is substantiated. The insurer's denial is reversed.

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