Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rib Ffractures and a broken breastbone
Treatment: Inpatient hospital admission 
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult male. He was injured in a motorcycle crash (into a car). The patient was wearing a helmet. The patient denied that he had lost consciousness. The patient was brought by ambulance to the hospital. The patient was confused on the scene but was alert and oriented upon arrival. The patient complained of left arm pain, shoulder pain, hand pain, abdominal pain, rib pain, and mild back pain. Trauma evaluation in the Emergency Department (ED) was notable for an anterior abdominal wall contusion and abrasions of the right arm and right knee. Vital signs in the ED were normal. The patient had a mildly elevated lactic acid level of 2.2. Computed tomography (CT) scan of the brain and cervical spine showed no injuries. CT scan of the chest revealed non-displaced left anterior rib fractures of ribs 3-6 (four levels), possible rib fractures on the right, mild buckle fractures of the lower sternum, and questionable spinous process fractures of thoracic vertebrae 6-7-8. Electrocardiogram (EKG) was normal. Serum troponins were normal. CT scan of the abdomen showed right para-midline soft tissue contusion with surrounding fat stranding. The patient was given lunch in the ED and ate 100% (percent). The patient was admitted to the trauma ward (non-intensive care unit [ICU]) for serial abdominal examinations. Regular diet was ordered in the morning on the next day. The patient was initially planned for discharge on this day. It is unclear why he was not discharged. Subsequent note on day 3 states patient was medically cleared for discharge on that day, but the patient developed emesis that day after receiving his home medications. Repeat CT of the abdomen and pelvis was ordered. The patient did not tolerate the oral contrast and the CT was done with intravenous (IV) contrast only. No missed injury was identified. The patient's pain remained well-controlled. Discharge summary was written on day 4. White blood cell (WBC) count, which was trending, was noted to be increased to 15,700 on day 4. The patient was discharged on day 5. The acute inpatient admission was denied as not medically necessary by the health plan. The health plan's determination is that the care rendered could have been done at observation level of care. 

This review is for an appeal of the acute inpatient admission. The hospital has appealed the denial of the acute inpatient admission. The stated care plan included neurologic and metabolic assessment, venous thromboembolism prevention/prophylaxis, and trending of lactic acid while receiving IV fluids. On day 4, the patient experienced emesis and was noted to have new periumbilical ecchymosis. WBC count was mildly elevated to 13,000 and lactic acid level remained elevated at 2.2.

The inpatient hospital admission was not medically necessary.

The patient should have been treated at a lower level of care. The care rendered did not warrant an inpatient level of care. The patient presented by ambulance to the hospital after being involved in a motorcycle accident when he ran into a car. The patient complained of shoulder pain, abdominal pain, rib pain, and mild back pain. Vital signs in the ED were normal. X-rays of the arm, shoulder, and knee showed no fractures. CT scan of the chest revealed non-displaced left anterior rib fractures of ribs 3-6 (four levels), possible rib fractures on the right, mild buckle fractures of the lower sternum, and questionable spinous process fractures of thoracic vertebrae 6-7-8. CT scan of the abdomen showed right para-midline soft tissue contusion with surrounding fat stranding. After evaluation, and while still in the ED, the patient was given lunch in the ED and ate 100%. The patient was initially written for discharge on the next day but was not discharged for unknown reasons. According to the notes, the patient could have been discharged within an observation period. Based on the information provided, the patient could have safely been discharged within the observation period. The inpatient admission was not medically necessary.