Diagnosis: Left acetabular fracture
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is approved, in part.

This is a female patient admitted to hospital. She had placement of a vena cava filter prior to reconstruction of left acetabular fracture (pathological). Her past medical history was significant for metastatic uterine carcinoma, urethral obstruction, sepsis and deep vein thrombosis (DVT) to lower left leg.

The patient's filter was placed and hip reconstruction was completed. She required several days to obtain satisfactory pain relief. She also required a psychiatric consult due to depression. She was discharged to home. She had a preoperative foot drop.

Yes, in part; the inpatient admission was medically necessary, in part.

Placement of IVC filters is a semi-elective procedure which does not require an overnight stay. The procedure was not emergent. There was the report of DVT weeks prior. The placement of the filter was to decrease the risk of thromboembolic events. It was non-complicated with no evidence of bleeding, infection or fever. Heparinization was initiated but required discontinuation prior to surgery. The IVC filter could have been placed the same day of elective surgery.

However, admission was required for the hip reconstruction. The patient's procedure was complex and extensive with blood loss. The patient had underlying chronic pain which required multimodal analgesia titration. In view of her unique medical condition, the days for the hip reconstruction were warranted. Milliman Care Guidelines (MCG) report a length of stay to be surgery plus two post-operative days. Extended is considered moderate of four to seven days (i.e., the patient's underlying morbidities).

The patient did not require inpatient admission for IVC filters. The medical records demonstrate no acute level services were provided. The patient was able to tolerate medications by mouth. Her vital signs were stable. She did not require treatment for other underlying medical conditions. Her hematocrit was stable. She was sufficiently anti-coagulated. No additional testing nor procedures were required. There were no extenuating circumstances to substantiate ongoing length of stay.