Diagnosis: Status Post (s/p) Surgery for Broken Bone in Jaw.
Treatment: Inpatient Stay.

The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male who was in a motorcycle accident and he did not report to the emergency room (ER) until 4 days after the accident. The patient was admitted and taken to the operating room (OR) and he was discharged the same day that he had surgery. The patient was denied an inpatient admission but received treatment at an alternate level of care for the treatment of a broken jaw. The patient had no significant medical problems or postoperative complications.

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

The inpatient stay was not medically necessary. The patient was treated with rigid fixation which meant his mouth was not wired closed. He was a healthy male and was sent home after surgery. His vital signs were stable. The patient was voiding, there were no respiratory problems, he was ambulating and tolerating his diet. The patient had stable vital signs, there were no infections and he had no difficulty breathing.

The denial agrees with the literature. A study of patients with mandibular fractures showed that an outpatient model to treat isolated mandibular fractures was not associated with an increased risk of postoperative complications. This outpatient care model reduced the hospital length of stay without increasing the risk of postoperative complications. This surgery is no more invasive than orthognathic surgery and these cases are routinely done on an outpatient basis.
An inpatient admission is not needed unless discharge criteria is not met within 23 hours. In the United States, it has been reported that between 46 percent (%) and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery.

Treatment at an alternate level of care would have been appropriate.