Diagnosis: Hindfoot Repair
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Upheld

The patient is a female who presented to the hospital for elective hindfoot repair. Her preoperative diagnosis was posterior tibial tendon insufficiency, foot deformity, and an equinus contracture. On the day of presentation, she underwent multiple surgical procedures including a double osteotomy of the calcaneus, bone grafting, and a tendon transfer.
According to her discharge summary, the patient had an "orthopedically uncomplicated hospital course." Included for review are medical records, and denial and appeal documentation.
This review involves denial of a full admission for a patient who underwent an elective hindfoot reconstruction. In the postoperative period, the patient was put on full inpatient status. This was denied by the insurance company as the care provided was thought to be able to be provided at a lower level of care.
The subject under review is the medical necessity for the full hospital admission.

The requested full hospital admission was not medically necessary for this patient.
The patient had comorbidities including smoking, hypothyroidism, anxiety and a family history of deep vein thrombosis (DVT), there was no exacerbation of any of these pre-existing medical conditions. The care provided the patient was pain control and physical therapy for mobilization. She was able to be discharged to home safely and had done well in physical therapy. All of the care provided can be done at a lower level of care status and does not require a full admission.
As described in the text box above, the patient had a routine orthopedic follow-up. She needed to stay at the hospital for pain control and physical therapy for a couple of days postoperatively, but did not have any exacerbation of premorbid conditions or develop new complications that required for intensive monitoring. The patient could have been safely managed at a lower level of care status.