Diagnosis: Periprosthetic fracture resulting from scooter accident.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He was involved in a scooter accident. His past medical history was significant for PSA (polysubstance abuse) detox, bacterial arthritis right shoulder and infection to prosthetic right hip. He was status post several hip procedures on the right.

The patient's x-ray showed an oblique fracture to his right mid femur. He was unable to bear weight. He was evaluated for surgery but transferred to another hospital.

No, the Inpatient admission was not medically necessary.

There was no indication for the admission. The patient was found to have a periprosthetic fracture with a significant history of prosthetic infection and revision. His diagnosis was known. He did not require treatment for an underlying medical condition. His vital signs were stable. He did not require additional imaging or an emergent procedure. There was no evidence of bleeding, acute infection, fever or intolerable pain. The services that were provided were "awaiting transfer" to another facility for definitive management. These findings do not substantiate the admission and level of care provided. There were no extenuating circumstances to warrant the inpatient stay.

The patient could have been treated at an observation level of care.