Hip Fracture denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for in-home skilled nursing visits and in-home physical therapy services, twice a week. As noted in the medical literature, skilled nursing level of care is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician, as well as constantly available skilled nursing services. Patients treated in home health skilled nursing care require skilled nursing services including wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of intravenous (IV) medications or medications that cannot be self-administered safely.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for treatment in an acute rehabilitation facility. This patient has a rehabilitation diagnosis of stroke. Her rehabilitation will most likely be complicated by her hip fracture. These two diagnoses require a higher level of rehabilitative care to help her progress in rehabilitation and decrease the likelihood of fall. A meta-analysis found that within the first 11.5 weeks after a stroke, patients with lower limitation in activities of daily living, higher functional independence, and better balance are more likely to have a higher quality of life one year after a stroke. These are modifiable risk factors and a clear argument for early acute rehabilitation, and this patient is in this timeframe window.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for aquatic therapy services consisting of 12 additional 30-minute sessions twice a week for six weeks. The records provided for review document that this patient is status post right hip hemiarthroplasty for a hip fracture after a fall in 2021. The provider noted that the patient has undergone extensive physical therapy. The patient has participated in aquatic therapy and she has been educated on a home exercise program. The patient has requested additional aquatic therapy services. As noted in the medical literature, exercise in an aquatic setting is one of several options for lower intensity exercise that can provide a more tolerable environment for exercise, as well as symptom relief for patients with various health conditions.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility level of care provided for treatment of the enrollee, who sustained a hip fracture. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Hip fractures are conditions that are known to substantially affect functional performance, and negatively impact both short-term and long-term health-related quality of life. In this case, the patient also has a history of prior intracerebral bleed with residual cognitive impairment and left hemiparesis. She had impairments in her mobility at baseline, further complicating her convalescence.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving hip fracture, then check the rights and deadlines that apply to your plan.