Diagnosis: Left elbow fracture.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay. The determination is overturned.

The patient sustained a left elbow fracture dislocation. He underwent multiple elbow surgeries, including open reduction and internal fixation on followed by ulnar nerve transposition and placement of a spanning elbow plate. The patient elected to undergo revision elbow surgery. This operation involved removal of the spanning elbow plate followed by revision open reduction and internal fixation of a displaced proximal ulna fracture with iliac crest bone graft. The surgery was successful with no documented complications. The patient, however, had a history of renal insufficiency, and his creatinine was elevated to 2.0 after surgery. He remained admitted to the hospital until his creatinine decreased to 1.5, at which time he was deemed stable for discharge. At issue in this case is the medical necessity of the inpatient hospital stay.

The requested health service/treatment of an inpatient stay was medically necessary for this patient. The provided medical records in this case document that the patient underwent revision elbow surgery with removal of hardware and open reduction and internal fixation of an olecranon non-union. The care rendered for this patient was consistent with the recommendations of the peer-reviewed literature as documented by Duckworth and colleagues in the Journal of Bone and Joint Surgery. The records document that this surgery was successful with no recorded complications. The patient however, had a history of renal insufficiency, and his creatinine was elevated to 2.0 after surgery. The patient was appropriately fluid managed and his creatinine decreased to 1.5. The patient was then deemed stable for discharge. The medical necessity of the inpatient stay is justified based upon the documented medial management of this patient's elevated creatinine level after surgery. Appropriate medical management of this condition required inpatient hospital admission. The patient's creatinine level was restored to 1.5, and he was deemed stable for discharge.