Diagnosis: Left Tibia and Fibula Fractures
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient is a male with a history of congestive heart failure (CHF), coronary artery disease (CAD), status post coronary bypass graft x (times) 5, diabetes mellitus (DM), deep vein thrombosis (DVT), hypertension (HTN), myocardial infraction (MI), peripheral vascular disease (PVD), angina, asthma, hyperlipidemia, and avascular necrosis of bilateral hips. The patient presented to the emergency department (ED) by ambulance for evaluation and management of left leg pain after a fall. Imaging showed left tibia and fibula fractures. Orthopedic Surgery was consulted, and the patient was admitted. The patient underwent surgery and received physical therapy and medication management postoperatively. He was discharged with follow up with his Primary Care Physician.

A review of the clinical record demonstrates the patient had significant comorbidities. He was reported to have recent discharge for CHF, he required oxygen while in the hospital, he had uncontrolled diabetes (Hb1Ac [glycated hemoglobin] > [greater than] 9) and mild hyponatremia. The patient had a non-complicated post-surgical course. There was no overall change in his condition. The main issue was placement, as he did not want to be referred to a rehabilitation facility. His pain was controlled with oral medication. His wound was without problem. He did not have an infection, nor was he bleeding. His vital signs were stable. His use of Lasix and diuresis was a chronic condition which was already managed. There was no documentation of an acute medical condition to require treatment nor imaging. There were thus no extenuating circumstances to warrant the admission and length of stay. A lower level of service would be appropriate.

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The inpatient hospital admission is not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.