Appeal type: Medical necessity
Decision: Upheld

 
Diagnosis: Partial traumatic amputation of the right middle finger status-post near complete amputation of the distal aspect of right middle finger; transection through the eponychium of the nail
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld.

This is the case of a toddler with no past medical history (PMHX) who presented to the emergency department (ED) with injury to her 3rd finger which was cut in the door. As per the triage note the patient was transferred another facility with a partial amputation of the middle finger of the right finger. The patient was afebrile with stable vital signs. The patient was given an apple to eat at 15:00. As per the ED provider note, on exam the right 3rd finger was in a splint. The diagnosis was partial traumatic amputation of the right middle finger. The patient was to be admitted for Operating Room (OR) management. Ambulatory Surgery Unit (ASU) pre-operative checklist showed the patient was nothing per oral (NPO) since 15:00. The patient was taken to the operating room. As per the operative note the patient had a near complete amputation of the distal aspect of right middle finger; transection through the eponychium of the nail. The fingertip was stabilized and sutured in place and nail was re-approximated. Surgery started at 19:52 and was completed by 20:27. The disposition was Post Anesthesia Care Unit (PACU) to home as per the operative note. The patient was discharged to home later that night.

Based upon the information provided, the hospital inpatient admission is denied as the patient should have been treated on an observation status without an acute inpatient admission. In fact, the brief operative note indicated disposition PACU to home. The patient was discharged on the same day as the procedure was done. This patient did not require acute inpatient admission but rather to have the procedure done in ambulatory/observation level of care. The vital signs were all stable and the patient was not in respiratory or cardiac distress. The patient could have been observed and did not require an acute inpatient admission to have this procedure done. 

As per MCG Health Guidelines MCG Health Guidelines General recovery care 27th Edition: musculoskeletal disease GRG: MG-MD (ISC GRG) hospital admission is needed for appropriate care of the patient because of 1 or more of the following: Bone, joint, muscle, or orthopedic device infection (e.g., periprosthetic infection that requires inpatient care; Vertebral fracture that requires inpatient care (Medical); Nonvertebral fracture, dislocation, or other musculoskeletal injury that requires inpatient care as indicated by compartment syndrome , major injury requiring inpatient care, severe pain requiring acute inpatient management; Rheumatologic disease  exacerbation or related finding that requires inpatient care; Vasculitis with complications or findings that requires inpatient care; Severe crystal arthropathy that requires inpatient care; Rhabdomyolysis that requires inpatient care; Myopathy that requires inpatient care; Postamputation complication that requires inpatient care; severe pain requiring acute inpatient management due to musculoskeletal condition. Furthermore, MCG  notes that there are alternatives to admission some include: Outpatient care in ED, observation care, rapid treatment site, urgent care center, or medical office: History and physical evaluation of stability, Analgesia, Non-steroidal anti-inflammatory drugs (NSAIDs). The reviewer, therefore, agrees with the insurer that the inpatient admission was not medically necessary at the acute inpatient level, as the patient could have been placed on an observation status. 

Based on the above, the insurer's denial must be 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 admission is not substantiated.