Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This patient presented to the emergency department (ED) with a complaint of a headache, left sided rib pain, and right wrist pain following a fall down stairs. She had comorbid health conditions that included a prior traumatic brain injury and seizure disorder. There was a reported loss of consciousness at the scene. Vital signs were stable at presentation. The Glasgow Coma Score (GCS) was 15 at the time of presentation. The initial evaluation included computed tomography (CT) scans of the head, face and chest that showed a small subdural hemorrhage on the right. An x-ray of the right hand showed a right 5th metacarpal fracture. She was admitted to the hospital for neurological monitoring every 2-4 hours. Neurosurgery and orthopedic consultations were requested.

She had normal vital signs and pain was controlled. A repeat CT scan of the head showed no change in the right subdural hemorrhage. Additional imaging was obtained with a magnetic resonance imaging (MRI) scan. Physical and occupational therapy evaluations were obtained with a recommendation for home therapy. Neurological checks were stable and vital signs were normal. She was tolerating a diet. She was discharged home with arrangements for short term follow up.

An inpatient level of care was appropriate. This patient presented to the ED following a fall down stairs. She had a loss of consciousness at the time of injury. The patient was found to have a subdural hematoma on CT imaging. She was appropriately admitted to the hospital with a neurosurgery consultation. Additionally, the patient had a 5th metacarpal fracture for which orthopedic surgery was consulted. The patient manifested functional deficits as noted by physical and occupational therapy consultations. She required the coordinated care of the trauma service, physical therapy, occupational therapy, and neurosurgery during the period of close neurological monitoring and repeat imaging. This multidisciplinary treatment was most appropriately provided in the inpatient setting. The 'brain bruise' noted in the health plan denial letter carries the significant potential for rapid clinical deterioration and warranted close monitoring as was provided in this case.

Inpatient admission for head injury is needed when 1 or more of the following is present:
Post resuscitation or presenting GCS is less than (<) 13, new focal signs on neurological exam, evidence of increased intracranial pressure (ICP), worsening of neurologic function post presentation, new intracranial pathology on imaging, hemodynamic instability, cerebrospinal fluid (CSF) leak, inpatient wound care needed, altered mental status that is severe or persistent, skull fracture, fracture of base of skull, intracranial infection, cerebral vasospasm, recurrent seizures, continuous infusion of medications, increased ICP or cerebral edema monitoring, other condition or monitoring requiring inpatient treatment.

In this case the patient had new intracranial pathology documented on imaging. She also required the coordinated care of multiple medical services that was most appropriately rendered in the inpatient setting during this time.