Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Fall from crib.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned. 

Yes, the Inpatient admission was medically necessary.

The patient is a female infant.  She presented to the ED after having fallen out of her crib.  She apparently climbed over the crib, and she fell head-first, hitting the back of her head.  This was unwitnessed by the mother.  There was one episode of projectile vomiting immediately following the fall, with no loss of consciousness but prolonged inconsolable crying. 

The patient's vital signs included temperature 37.6, heart rate 165, respiratory rate 36, and 100% saturation in room air.  Examination was significant for active and vigorous appearance, clear ears, no palpable skull step-offs, clear lungs, regular heart rate and rhythm, and non-focal neurologic exam.  Per the family, she was at her baseline mental status and activity level, with no significant soft tissue injuries and no palpable skull fractures.  She was given intranasal Versed for head CT, with negative results, after which she had an episode of vomiting, treated with Zofran.  She remained continuously fussy, crying with tears, inconsolable by the mother. 

The decision was made to admit for further monitoring for sequelae of suspected concussion.  Admission orders included neuro checks every four hours, Tylenol as needed, and regular diet for age.  The patient did well following admission, feeding well with no further episodes of vomiting.  She had no concerning neurological signs noted during neuro checks.  She was deemed stable for discharge home to follow-up with her pediatrician in two to three days.

The majority of traumatic brain injuries (TBI) in patients presenting to the ED are considered to be mild, as defined as Glascow Coma Scale (GCS) 14, or GCS 15 with less than five minutes loss of consciousness or alteration in memory or alertness.  Management is based on risk stratification.  Patients at low risk for intracranial injury are either asymptomatic or have the following symptoms:  headache; dizziness; scalp hematoma, laceration, contusion, or abrasion; no moderate or high-risk criteria; and no history of loss of consciousness. 

Symptoms consistent with moderate risk if intracranial injury include the following:  history of change or loss or consciousness on or after the injury; progressive headache; alcohol or drug intoxication; post-traumatic seizure; unreliable or inadequate history; age less than two years unless trivial injury; vomiting; post-traumatic amnesia; signs of basilar skull fracture; multiple trauma; serious facial injury; possible skull penetration or depressed fracture; suspected child abuse; and significant subgaleal swelling. 

Findings consistent with high risk of intracranial injury include the following:  depressed level of consciousness not clearly due to alcohol, drugs, metabolic abnormalities, or postictal; focal neurological findings; decreasing level of consciousness; and penetrating skull injury or depressed fracture. 

Patients in the low-risk group may not need a CT scan.  They may meet criteria (not included here) for observation at home.  Patients in the moderate risk group will most likely need a CT scan, and occasionally may also require skull x-rays.  These patients may also qualify for home observation, but only if their only moderate risk factor is loss of consciousness.  Those in the high-risk category require hospitalization, CT scan, and may need surgery.  In general, patients with occipital fractures are at higher risk for intracranial injury.

This infant fell from her crib head-first, striking the back of her head, with no loss of consciousness but two episodes of vomiting (once immediately after the fall and once in the ED), was taken to the ED for evaluation.  She was crying and inconsolable, so even with a negative CT scan, she was admitted for monitoring.  Because of her age, inconsolability, and two episodes of vomiting, she would be considered at moderate risk for intracranial injury and not appropriate for home observation.  Hospitalization for ongoing observation was thus medically necessary and appropriate.