Diagnosis: Right knee osteoarthritis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a female with osteoarthritis to her right knee. She was admitted to the hospital for an elective arthroplasty. Her post-surgical course was non-complicated. She had removal of pain catheter several days after admission. She felt light headed on that date. Monitoring was provided. She was discharged to subacute rehab.

The medical record demonstrates the patient underwent a complex and extensive surgical procedure. She required post-surgical management based upon the amount of pain anticipated and associated rehabilitative/anesthesia services necessary. A pain catheter was placed which required monitoring for position and effect. This type of operation requires rehabilitative services. After knee arthroplasty, these services initially can only be provided at inpatient setting. She would also require monitoring for blood loss as anemia is common after replacement surgery.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

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