According to the CDC’s National Center for Health Statistics*, there are 130 million visits a year to Emergency Departments, 35 million of which are injury related. Many injury-related ER visits do not result in admission to the hospital, but for those that do, hospital utilization review managers need to provide insurance companies sufficient documentation showing the cause for admission in order to avoid an inpatient denial.
CLINICAL SUMMARY: Ankle Injury with Complex Medical History
A 68-year-old patient arrived in the ER with severe pain, numbness and injury to her left ankle due to a fall at home. The patient had metastatic ovarian carcinoma and was undergoing chemotherapy with carboplatin and paclitaxel. Paclitaxel dose was reduced prior to this incident due to worsening peripheral neuropathy. The last chemotherapy session was six days prior to the fall. The patient’s medical history included obesity, type 1 diabetes mellitus with an insulin pump, hypertension, hyperlipidemia, hypothyroidism, COPD, and asthma (using O2 at home). Labs were WBC 6.74; Hgb 7.6, 7.2; PLT 222; Na 133, 135; K 4.6; BUN 40, 40; Cr 1.08; and GLU 101-206.
An x-ray in the ER showed a complex fracture, dislocation of the left ankle for which the patient underwent a closed reduction and application of a splint. Later that day, the patient underwent open reduction and internal fixation by orthopedic surgery of a trimalleolar ankle fracture. The patient was admitted postoperatively for IV antibiotics, IV pain control and physical therapy. Postoperatively, the patient had poor glycemic control as well as elevated creatinine. The patient’s hospital stay was six days. Throughout the hospitalization, the patient continued to require IV pain medication for pain control as well as medication adjustment for blood glucose, electrolyte abnormalities and tighter blood pressure control.
At one point, the patient’s hemoglobin was 7.3 g, however the patient refused transfusion. Prior to discharge, the patient’s blood pressure was better controlled as well as her blood glucose and electrolytes. She was accepted into a skilled nursing facility upon discharge.
DENIED INPATIENT STAY
The six-day “acute inpatient hospital admission” was denied by the insurance company based on Medicare and health plan criteria which called for severe symptoms and services that can only be provided in an inpatient setting. The insurance company initially determined that the criteria had not been met due to the following rationale: “no available documentation of an insufficient response to treatment, need for intervention or presence of a condition not likely to improve in a lower level of care.” The insurance company stated that there were no abnormal lab or diagnostic findings such as hemodynamic instability, respiratory distress or surgical complications that required an inpatient level of care.
An AppriseMD physician advisor conducted a Peer-to-Peer discussion with the insurance company’s medical director for this case. As a result of the conversation and a review of the case, the medical director agreed with inpatient level of care for this patient admitted with a complex trimalleolar ankle fracture. The patient’s complex medical history including metastatic ovarian carcinoma undergoing current chemotherapy and the urgent surgical intervention needed for her injury as well as post operative episodes of hypoglycemia and AKI justified the inpatient level of care, and the denial was overturned.
OUTCOME: DENIAL OVERTURNED