Diagnosis: Osteoarthritis

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is overturned.

This is a female patient with a history of asthma, morbid obesity, hypertension and osteoarthritis. The patient was admitted to the hospital for an elective right total knee replacement. The patient's post-surgical course was non-complicated. The patient received physical therapy services and post-operative medications. The patient was discharged to a skilled nursing facility.

Based on the review of the medical record and literature, the records demonstrate factors to substantiate this patient's inpatient admission and length of stay. The patient has underlying problems which support the inpatient level of care and treatments provided. The patient received anesthesia of almost 4 hours, which contributes to delays in this patient's mobilization. The patient has a body mass index (BMI) of 43 and previous total knee replacement on the left-side. Given these conditions, the patient would be expected to have difficulty with post-operative mobilization. The patient would have difficulty arising and move without assistance. The patient was at high-risk for a fall, and it was important that this patient reached full rehabilitative potential prior to transferring to a skilled nursing facility. The patient had difficulty getting out of bed and inability to walk more than 10 feet. There was a reported episode of dizziness and the need for the patient to sit down. Gradual progress was made where walking was able to be increased to 50 feet. The patient's physical therapy progress gradually improved. The patient's admission and length of stay were warranted by her underlying comorbidity and clinical course.

The full hospital admission is considered medically necessary for this patient.

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

The carrier's denial of coverage for the full hospital admission should be overturned. The medical necessity is substantiated.