Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute comminuted multipart fracture of the mid to distal left clavicular diaphysis and multiple rib fractures with tiny pulmonary contusion status-post fall of motor cycle
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
An adult who presented to Emergency Department (ED) per triage note patient presented ambulatory to triage with steady gait, complaining of left rib, left arm and collarbone pain post falling off a motorcycle. The patient denied loss of consciousness (LOC). The patient reported pain upon exhalation. The patient presented with clavicle, rib pain. The patient was going at low speed and fell to the left side. The patient had a skull helmet on and denied head injury. The patient reported pain in the left clavicle and ribs/back and worsens with breathing. The patient took nothing for pain and came straight to the ED. Vital signs were stable. On exam the patient had tender to palpation to his left mid thoracic region and left clavicle. White blood cell count (WBC) was 15.7k. Computed tomography (CT) of the chest showed acute comminuted multipart fracture of the mid to distal left clavicular diaphysis and acute comminuted non displaced seventh and eight left posterior thoracic rib fractures and non-displaced sixth left posterior thoracic rib fracture and minimally displaced sixth through eight left lateral thoracic rib fractures. There was no evidence of pneumothorax and trace pulmonary contusion within the lingual. Radiographic image (x-ray) clavicle showed comminuted mildly displaced left clavicle fracture; x-ray of the forearm showed mild soft tissue swelling is present. X-ray of the hand showed no acute fracture was identified, x-rays of the ribs showed mildly displaced left posterior seventh and eighth rib fractures and comminuted mildly displaced left clavicle fracture noted.

Trauma consult noted the history of motorcycle accident. Glascow Coma Score (GCS) was 15. Trauma consult noted multiple left sided fractures including comminuted clavicular fracture, left 6-8 ribs and tiny pulmonary contusion and no pneumothorax. The plan was to admit to telemetry, multimodal analgesia and Orthopedic consult for clavicular fracture. The pain was controlled and the patient was on Rib Fracture protocol. The patient was on a regular diet and was stable. Occupational Therapy (OT) saw the patient and noted anticipated discharge with outpatient therapy services. Orthopedics saw the patient and noted no acute Ortho-surgical intervention at this time. The left upper extremity (LUE) was to be in a sling and non-weightbearing (NWB). The patient was discharged with outpatient OT services.
	
Based upon the information provided, the hospital inpatient admission is denied as the patient should have been treated in an observation status without an acute inpatient admission. This patient did have acute comminuted multipart fracture of the mid to distal left clavicular diaphysis; Acute comminuted non-displaced seventh and eighth left posterior thoracic rib fractures; Non-displaced sixth left posterior thoracic rib fracture; Minimally displaced sixth through eighth left lateral thoracic rib fractures. The patient was otherwise stable and did not need an acute inpatient admission. The vital signs were always stable and no respiratory or cardiac distress noted. Labs were stable. The patient should have been observed and sent home without a full admission. 

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