Diagnosis: varus deformity of the left femur and tibia
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a woman with X-linked hypophosphatemic Vitamin D-resistant rickets. Treatment has included monthly injections of burosumab and osteotomies of her right femur and tibia to address varus deformity. She had varus deformity of the left femur and tibia and underwent osteotomies of the left femur and tibia with internal fixation using interlocking intramedullary nails. She also had a prophylactic fasciotomy of the compartments of the left leg. Spinal anesthesia as used, and postoperatively the patient had a Dilaudid PCA (patient-controlled analgesic) pump for pain control.

The inpatient hospital admission was medically necessary.
Osteotomy of the femur and tibia are both major surgical procedures with some risk of complication, and both could be expected to lead to substantial post-operative pain, possible need for transfusion, and the need for careful monitoring. Even with the prophylactic fasciotomy, there is some risk of compartment syndrome which can be difficult to detect. The procedure was lengthy, the patient had spinal anesthesia and a PCA (patient-controlled analgesic) pump and had surgery on both her femur and the tibia; slow mobilization and difficulty carrying out activities of daily living would be expected after this type of surgery. The intensity of the care required by this patient justifies inpatient hospital admission.