Diagnosis: Trauma/Injuries/Injury.
Treatment: Inpatient Hospital.

The health plan denied the requested inpatient hospital stay as not medically necessary.

The health plan's determination is upheld.

This is the case of a female with a history of Antiphospholipid Antibody Syndrome, on Plaquenil and noncompliant with Warfarin, who presented to the emergency department after a fall down 6 steps. The patient had no broken bones or other injuries. She did have significant pain in her left knee and ankle. She was seen by orthopedic surgery, who recommended a knee immobilizer. She was admitted for pain control and physical therapy. She was discharged to home. The issue is whether an inpatient admission was medically necessary.

I uphold, in whole, the health plan's determination of medical necessity.

No. This is not a medically necessary inpatient stay. The patient had no significant injuries warranting an inpatient stay. The patient was hemodynamically stable. The patient had no surgeries requiring an inpatient stay. The admission was listed as for "pain control" in the history and physical (H&P). The pain control provided was Tylenol, Ibuprofen, and Oxycodone. These medications do not require an inpatient level of care. As an example of a peer reviewed level of care reference, this stay would not qualify for inpatient necessity by InterQual standards. This patient did not require an inpatient stay.