Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Assault by Sharp Object. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of a female with past medical history of hypertension who presented to the Emergency Department (ED) after being stabbed the night prior. The patient stated she was picking up bottles and a random person ran by her and punched her. She later found herself to be bleeding and eventually went to urgent care and was then sent to the ED for further work up. As per the ED triage, the vital signs were stable. As per the ED provider note, the patient complained of a puncture wound. Exam revealed the abdomen to be soft non-distended, without rebound or guarding. There was a 0.5 centimeter (cm) laceration to the right flank with surrounding rebound and guarding. The reassessment noted the patient was resting comfortably with stable vital signs and mental status. Trauma service was called, and the patient was admitted as computed tomography (CT) showed right lower quadrant (RLQ) with arterially enhancing focus with tract suggesting active hemorrhage. The plan was nothing by mouth (NPO), intravenous (IV) antibiotics. Hemoglobin (Hb) was 11.8. The plan was to repeat CT and admit the patient to the stepdown unit. The patient was noted to be hemodynamically stable. The plan was frequent monitoring, NPO with follow up labs. Repeat labs showed an Hb of 10.7. Repeat CT showed stable RLQ hemorrhage with no gross evidence for extraluminal gas or oral contrast extravasation. 

The concern was for active bleeding or injury which would have led to hemodynamic instability. Using Milliman Care Guidelines (MCG) Health Inpatient and Surgical care 25th Edition: Hemodynamic instability: common complications and conditions (CCC): admission was not justified. MCG notes that ongoing inpatient care may be indicated for hemodynamic instability as indicated by 1 or more of the following: Hypotension that is new or symptomatic; Symptomatic tachycardia or bradycardia unresponsive to treatment (e.g., analgesia, fluids); Inadequate perfusion as indicated by 1 or more of the following: altered mental status that is severe or persistent; Orthostatic vital sign changes that are symptomatic and unresponsive to treatment (e.g., fluids); IV inotropic medication or vasopressor medication required. This patient did not meet any of these guidelines to require inpatient care as the patient was normotensive in the ED and was not symptomatic. 

Based upon the information provided, the hospital inpatient admission is denied as the patient could have been treated on an observation status without an acute inpatient admission as this patient was observed for hemorrhage after having been stabbed more than 24 hours prior to the presentation to the ED. The patient did not meet criteria as noted by the insurer as there were no associated risk factors that would have necessitated inpatient surgery. MCG Health Guidelines General recovery care 25th Edition: Multiple Trauma notes that hospital admission is indicated when patients with significant multiple trauma requires inpatient care for 1 or more of the following: major surgical and post-procedural care; non-operative care of significant injury. This patient did not meet any of the criteria as she only needed observation as she did not have a significant injury requiring inpatient status. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

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