Diagnosis: Fibula Fracture

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a past medical history of an open reduction internal fixation (ORIF) of her left leg and post-polio syndrome. She presented to the Emergency Department with complaints of pain to the right foot; the patient had sustained injury. The patient's x-ray demonstrated a fracture to her distal fibula. The patient was admitted to the hospital and orthopedic consultation was provided. Their recommendation was a short leg cast. The patient was discharged from hospital after a period of medical stability.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient had sustained right ankle fracture. The patient was found to have fractured the distal fibula with associated ligamentous damage (i.e., stress view showed widening). This injury is common and not complex. The patient did not require anesthesia for closed or open reduction. The patient was treated by Orthopedics with application of a short leg cast. This management could have been provided in an outpatient setting. It could have also been completed in a physician's office. There were no other medical problems which required inpatient management. The patient did not report pain and was able to tolerate oral medications. The patient's physical therapy (PT) services could have been provided at a lower level of care. Mobilization could also have been provided by wheelchair. No additional testing or specialized consultation was required. There were no extenuating circumstances to substantiate acute level admission for the diagnosis of closed ankle fracture.

The health care plan acted reasonably 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 not substantiated. The insurer's denial should be upheld.