Diagnosis: Open fracture to the distal phalanx right little finger.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This is the case of a male with no significant past medical history. He presented to the emergency room (ER) with complaints of right pinky pain from an injury 9 days prior to arrival. He was given intravenous (IV) antibiotics and IV pain medications. Imaging revealed an open fracture. The patient underwent an open reduction internal fixation (ORIF) of the right 5th finger. After surgery he was given IV antibiotics, IV pain medications, and IV fluids. He was discharged after a period of hemodynamic stability.

The medical records document a diagnosis of an open fracture to the distal phalanx right little finger. The condition is not complex nor extensive. Simply stated the man sustained a crush injury to the tip of his right little finger 9 days ago.

He underwent surgical management consisting of exploration, irrigation, and open reduction to the distal phalanx. The operation was 12 minutes. The blood loss was 2 cubic centimeters (cc). His post-surgical course was non complicated.

There was no evidence of bleeding nor wound problems. His vital signs were stable. He was able to tolerate oral pain medication. He did not require additional imaging nor treatment for other medical conditions. These services could have been provided at a lower level of care. There were no extenuating circumstances to substantiate admission and length of stay.

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

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