Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Assault by unspecified object
Treatment: inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld.

The patient is a male with no significant past medical history (PMHX) who presented to the emergency room (ER) with complaints of stab wound after being assaulted. A Focused Assessment with Sonography for Trauma (FAST) exam was done and was negative for penetrating injury to the abdomen with no gross free fluid noted.

As per the general surgery consult for level trauma activation, the patient presented after sustaining multiple stab wounds to the face, left back, and right thumb. He was stabbed by someone first in the back, and then in the face. He denied shortness of breath (SOB), loss of consciousness (LOC), nausea or vomiting. He arrived mentating appropriately and perfusing well. On exam, he had a 3 centimeters (cm) laceration to the left flank, posterior to the posterior axillary line, a 3 cm laceration to the left side of the face, and superficial laceration to the right hand. The plan was X rays, pain control and trauma surgery to follow after imaging.  The emergency department (ED) physician noted that the patient required admission for inpatient services for concern for a serious outcome if the patient is not closely monitored. In addition, it was noted that the patient was COVID-19 (Novel 2019 Coronavirus) positive. As per the emergency department (ED) provider note, the patient presented with level 1 trauma due to stab wound to the face and left flank. At presentation to the ED, the patient's vital signs were stable, mentating and perfusing well. He had a 3 cm laceration with mild oozing over the left side of the face and 3 cm laceration to the left flank posterior to the posterior axillary line with mild oozing.

Milliman Care Guidelines (MCG) guidelines 25th edition Multiple traumas are not met: test results showed no broken bones and no free air in the belly/pelvis area. The patient was treated with antibiotics, fluids by vein, wound care and monitoring. The patient was sent home the next day. There are no notes that the patient had an abnormal blood pressure (BP) or heart rate after treatment; no notes that the patient had an abnormal breathing rate after treatment; no notes that showed that the patient did not improve after observation care, and that the patient needed to stay in the hospital. There are no notes that the patient needed surgery right away in the hospital, and that surgery could not be done on the same day as the treatment. Based on the notes sent to the insurer, the care could have been given in the emergency room or the observation area. 

As per MCG Health Guidelines General recovery care 26th Edition: Multiple trauma Hospital admission is indicated when patient with significant multiple traumas requires inpatient care for 1 or more of the following: Major surgical and postprocedural care; Nonoperative care of significant injury; multiple trauma and one or more general admission criteria. MCG notes that alternatives to admission include: Outpatient care in emergency department, rapid treatment site, or urgent care center, X-rays and wound care as indicated, Surgical evaluation, Diagnostic testing (e.g., CT scan, ultrasound), Observation of patient without urgent surgical requirements, Repeat testing (e.g., hematocrit, ultrasound); Home care: Wound care, Facilitation of specialty follow-up, Physical therapy. This patient could have been treated in an outpatient care status with observation rather direct inpatient admission. 

This patient did not have the indications for admission based upon the above criteria. 

Based on the above, the insurer's denial is 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 the inpatient hospital admission is not substantiated.