Diagnosis: Osteoarthritis, left hip

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld.

According to the documentation submitted, this is a patient with a history of gastroesophageal reflux disease (GERD), hypothyroidism, osteoarthritis, and polycystic ovarian syndrome (PCOS). She presented to the hospital for a scheduled left hip replacement surgery.

The medical records demonstrate a non-complicated post-surgical course after Mako robotic hip arthroplasty. The procedure itself was approximately one hour with limited blood loss. The patient's vital signs were stable. There was no evidence of bleeding nor infection. Her wound was without problem. She was able to tolerate oral pain medication with chart noting pain level zero and she was awaiting physical therapy (PT). The attending record reported hemodynamically stable and for disposition planning after physical therapy/occupational therapy. She had been evaluated by PT and was instructed on the use of cane and rolling walker. Her discharge summary, completed later that evening, reported a non-complicated course.

She did not require treatment for an underlying medical condition nor require additional imaging. Her body mass index (BMI) was taken into consideration (35.7).

These findings do not substantiate necessity of acute level admission. The services would be provided at a lower intensity.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.