Diagnosis: Total hip replacement

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a patient with a history of diabetes mellitus, dissecting AAA (abdominal aortic aneurysm), gout, DVT (deep vein thrombosis), kidney stone, osteoarthritis, peripheral vascular disease, reflux esophagitis. The patient had a replacement total hip computer assisted navigation procedure in The Hospital for Special Surgery. The patient received 24 hours of prophylactic antibiotics postoperatively and Aspirin then Eliquis for DVT prophylaxis. Patient's pain was managed on oral pain medication. Postoperative asymptomatic tachycardia was treated with intravenous (IV) hydration.

The medical records demonstrate a person at high risk for complications. Several factors were taken into consideration. They were the Body Mass index (BMI) of greater than 35, the previous history of aneurysm, American Society of Anesthesiologists (ASA) score of 3 and peripheral vascular disease (PVD). A post-surgical event occurred where there was concern for a pulmonary embolus. There was evidence of tachycardia (one occasion 130 beats per minute) and reported pulse oxygen at 93 percent saturation on room air. There was high suspicion for a thrombotic event to require special imaging and change in treatment (bolus of IV fluid). Observation and monitoring would be mandatory. This type of service could not be provided at a lower level of care. A full hospital admission was subsequently required.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is substantiated.