Diagnosis: Hip pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female with spastic quadriplegia CP (cerebral palsy), status post multiple spinal surgeries complicated by infection. She presented to hospital on with right hip pain. She had previously undergone removal of hardware from her spine and replacement with plastic closure. She required readmission for Baclofen withdraws. She presented with ongoing hip pain and was admitted. She underwent aspiration, removal of hardware and irrigation/debridement. Her post-surgical course was non-complicated.

Yes, the Inpatient admission was medically necessary.
The records show the young girl had a complex, unique and extensive clinical condition. She was a quadriplegic CP (cerebral palsy) patient with a history of multiple infections. She would be at extremely high risk for complications. She was immunocompromised and required treatment by several subspecialties.

The patient required infectious disease evaluation as it would be important to assess whether a chronic infection was present to a new site (Hip). This would require awaiting culture reports as treatment would change based upon presence of infection. She required empiric IV (intravenous) antibiotics while awaiting the cultures. She required laboratory assessment of inflammatory markers.

The patient was bedbound and when seen by PT (physical therapy), and could not move her hip. She was not able to be mobilized to wheelchair. She had severe limitations and had spasm to require multiple medications.

It would be important to monitor the patient wound for evidence of drainage.

Based upon the complexity of the patient's condition, the admission and length of stay were appropriate. These services could not have been provided at a lower level of care.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.