The patient is right handed with past medical history of mechanical valve on chronic anticoagulation, history of cerebrovascular accident (CVA) with mild aphasia, diabetes mellitus type 2, permanent pacemaker, coronary artery disease and hypertension who presented to the emergency department after injuring the right hand following a mechanical fall in her shower. The patient sustained laceration to the volar aspect of the right middle and ring finger with injury to FDP (flexor digitorum profundus) and FDS (flexor digitorum superficialis) tendons. The patient was seen urgently by orthopedics who recommended surgical repair due to the "devastating nature of injury". The patient had urgent cardiac clearance. The international normalized ratio (INR) was 2.1 in the ED and the patient was given 2 milligrams (mg) of vitamin K, with plan for fresh frozen plasma (FFP) if INR not < 1.7. The INR was acceptable for surgery and the patient went to the operating room (OR) and had I & D, wound exploration and right middle and ring finger tendon repair. The patient remained anticoagulated on Lovenox as it was necessary for the patient to be anticoagulated due to the mechanical valve. The patient was unable to administer Lovenox injections as she was right-handed.

The health plan's determination is overturned. The inpatient stay is under review. The patient required close monitoring for bleeding and frequent neurologic checks of the affected extremity with urgent consultation with orthopedics and cardiology. The patient required urgent procedure to repair two tendons that were injured on the dominant hand. It is medically necessary for patient to remain anticoagulated given the mechanical valve, but the patient was not able to administer lovenox due to the injury to the dominant hand. Per Milliman Care Guidelines (MCG) guidelines for musculoskeletal surgery or procedure the patient meets inpatient criteria as she did have 1) fracture, dislocation or other skeletal injury requiring procedure of "other operative repair" as well as wound or soft tissue injury with repair needed for complex wound closure. In summary, the inpatient hospitalization was medically necessary for this patient.