Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Subdural hematoma.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient fell and was found to have a subsequent subdural hematoma. She was admitted to the hospital, and this hospital stay was not approved. The provider has appealed this denial.

The insurer stated, "the plan considers a full hospital admit for a head injury necessary when someone remains confused or there are other severe problems."

The hospital appealed, and noted the patient was bleeding from her mouth, had a history of recent deep vein thrombosis (DVT), is treated with Xarelto, and also had endometrial cancer. She was noted to have a 2 millimeter (mm) acute right frontal and tentorial subdural hematoma. She was also noted to have a history of fracture of the right radial head. After her fall she had an elbow fracture and a hematoma in the right knee. She was advised to wear a sling for the right arm and to engage in physical therapy (PT) as tolerated. 

The General Surgeon noted the patient requires admission for inpatient services because of "concern for a serious outcome if patient is not closely monitored as an inpatient due to patient admitted due to subdural hematoma on Xarelto." She noted the patient "states her slippers were caught in the door leading to fall on to face and right knee and right elbow." She denied loss of consciousness (LOC) and had no headache and no nausea or vomiting and no vision changes. On exam she was noted to have clear and fluent speech with no aphasia and no pronator drift and sensation was grossly intact.

The Emergency Medicine Specialist noted "she has a 2 mm acute subdural hemorrhage... she is currently ambulating with stable gait around the Emergency Department, and she has mildly antalgic gait and complains of headache." Because of the headache and the finding of subdural hematoma and the use of Xarelto, it was determined that "the patient was critically ill with high probability of imminent or life-threatening pathology," and admission was arranged.

Per Soleimani, et al (2021), "Based on the results of this study, patients who sustain a blunt head injury while taking only direct oral anticoagulants (DOACs); that is, without concurrent antiplatelet medication, admission, and repeat head computed tomography (CT) may not be necessary after confirming a negative initial CT scan."

Per Wei, et al (2021), "The base-case scenario estimated that older adults treated with no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban had quality-adjusted life years (QALYs) of 8.03, 8.69, 10.38, 11.02, and 11.56, respectively. The sensitivity analysis estimated that an older adult would need to fall over 45 (rivaroxaban) and 458 (apixaban) times per year for the QALY of a DOAC to be lower than that of aspirin... Conclusions: Older adults with atrial fibrillation benefit from stroke protection of anticoagulants, especially direct oral anticoagulants, even if they are at high risk of falls."  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.