Diagnosis: Left distal humerus fracture.
Treatment: Inpatient Stay.
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient was diagnosed with a left distal humerus fracture. The patient presented to the emergency department after a slip and fall resulting in a midshaft humerus fracture five days prior to presentation. The patient had been seen at another emergency department and was placed in a cast and sent home on pain medication. The patient did well until one day prior to presentation when the pain increased. The fracture could not be effectively immobilized in a brace because it was too distal. The documentation indicates that there was displacement of the distal humerus fracture. The patient underwent open reduction internal fixation of the left distal third humeral shaft fracture with application of a long arm splint.
At issue is the medical necessity of an inpatient stay.

No. The inpatient stay was not medically necessary.

The documentation indicates that the patient was diagnosed with a displaced midshaft humerus fracture but was otherwise in stable condition. The open reduction internal fixation was performed. A clinical note from the next day states that the patient felt lightheaded during morning rounds. The blood pressure was measured at 70/35. A 10 milliliter (mL)/kilogram intravenous (IV) normal saline (NS) bolus was administered, and the blood pressure normalized to 109/65. The patient reported feeling much better afterward. The documentation does not suggest that there was an acute clinical scenario that required the inpatient level of care versus treatment at a lower level of care. Based on the available information, the inpatient stay was not medically necessary for this patient.