Diagnosis: Arthritis, left knee

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned.

This is a female with a history of arthritis of the left knee. She presented to the hospital for a left anterior cruciate ligament (ACL) repair. The procedure was performed without complications. The patient was admitted to Orthopedics for postoperative care. Pain was well controlled, and the patient was able to void. The patient had a nerve block and could not move her foot or feel sensation. The plan was to continue with pain control, administer 325 milligrams (mg) of oral (PO) aspirin twice a day (BID), encourage use of an incentive spirometer, monitor motor and sensation, and follow physical therapy (PT) recommendations. The patient's condition improved, and she was discharged.

The records show the patient underwent a complex orthopedic procedure consisting of a medial compartment arthroplasty and revision ACL (not a primary ACL). The time in the operating room was greater than 6 hours. Her tourniquet time was close to three hours.

Her post-surgical course was complicated by loss of feeling to the extremity. She was unable to move it and was also in a knee immobilizer. The PT records showed she could be mobilized less than 4 steps with rolling walker. Taking into consideration her elevated body mass index (BMI), she was unlikely to be independent and required additional acute PT services. Discharge to home would not be an appropriate option at that time.

In conclusion based upon the extent, duration of surgery and post-surgical course, admission and length of stay were appropriate.

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

The hospital admission is considered medically necessary for this patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.