Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Stab Wound To The Abdomen.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male that sustained a stab wound to the lower abdomen. The patient presented to the hospital after the wound continued to bleed. The patient was seen by Surgery as a Level 1 (the highest level) trauma activation.

At presentation, the patient had normal pulse and blood pressure. He was tachypneic (breathing 20-22 breaths per minute). A 1 cm (centimeter) stab wound was noted to the periumbilical area of the abdomen which was actively bleeding. The abdominal exam was benign except for some tenderness around the stab wound. The patient underwent laboratory testing and CT (computed tomography) scan of the abdomen and pelvis in the Emergency Department. Laboratory values showed a mild decreased sodium. Hemoglobin, white blood cell count, and platelet values were normal. Venous blood gas showed a respiratory acidosis.

CT (computed tomography) scan showed the stab wound extended through into the subcutaneous tissue and through the anterior rectus sheath with muscle tear. There was no penetration of the peritoneum or posterior rectus sheath. There was hematoma in the left preperitoneal space. There were tiny hyperdensities in the subcutaneous fat concerning for pseudoaneurysm.

The wound was cleaned and packed with placement of an abdominal binder. The patient was administered DTP (diphtheria, tetanus, pertussis) vaccination (for tetanus). The patient was admitted to acute inpatient level of care to the floor (not ICU [intensive care unit]). Admission orders included NPO (nothing by mouth) status, oral analgesia medication, and intravenous fluids.

On hospital day # 2, the patient was re-evaluated by surgery. The wound packing was removed and there was no active bleeding. The abdominal exam was otherwise benign. The patient was discharged to home. 

Coverage of the acute inpatient admission was denied by the health plan as not medically necessary. This review is for the denial of the acute inpatient admission / level of care.

The hospital, through its agent has appealed the denial of acute in-patient services. The MCG (Milliman care guidelines) 25th Edition for Multiple Trauma under clinical indication for admission to inpatient care and general admission criteria. The specific criteria cited are that the patient required surgical evaluation, cardiac monitoring, pulse oximetry, and hemodynamic monitoring, maintained NPO (nothing by mouth), serial abdominal exams, wound care, monitoring for bleeding, intravenous fluids and pain management.

General Admission criteria cited are that the patient required vital sign checks more than every 4 hours, and that cardiac and respiratory monitoring was beyond the scope (e.g., > [greater than] 24 hours) of observation care.

The appeal notes that the patient could not have been safely managed at a lower level of care or in the outpatient setting.

No, the Inpatient admission was not medically necessary.
The patient is a male that sustained a stab wound to the lower abdomen. The patient presented to the hospital, brought in by a friend. At presentation, the patient had normal pulse and blood pressure. He was mildly tachypneic (breathing 20-22 breaths per minute). A 1 cm (centimeter) stab wound was noted to the periumbilical area of the abdomen which was minimally bleeding. Hemoglobin level was normal and the patient was not tachycardic. The abdominal exam was benign except for some tenderness around the stab wound.

The usual first line treatment for a stab wound to the abdomen in a mildly symptomatic patient is local exploration of the wound in the emergency department. In this case, a CT (computed tomography) scan of the abdomen was done to evaluate the depth of penetration. CT (computed tomography) scan showed the stab wound extended through into the subcutaneous tissue and through the anterior rectus sheath with muscle tear. There were no signs of peritoneal penetration. Standard of care in asymptomatic or mildly symptomatic patients with penetration of the anterior aponeurosis should undergo physical examinations every 6-8 hours for 24 hours. If there are no changes in examination the patient can safely be discharged. The patient remained hemodynamically stable with no signs of peritonitis.

On hospital day # 2, the patient was re-evaluated by surgery. The wound packing was removed and there was no active bleeding. The abdominal exam was otherwise benign. The patient was discharged to home. The care rendered did not require an acute inpatient level of care. The patient could have been treated at a lower level of care.

Yes, the health plan acted reasonably and with sound medical judgment in the denial of the acute inpatient level of care.
The patient sustained a stab wound the abdomen in an altercation. He was hemodynamically stable on arrival to the emergency department and throughout his hospital stay. CT (computed tomography) scan did not indicate penetration through the peritoneum but rather a muscle injury of the rectus muscle. Standard of care is observation with serial abdominal examinations. This is typically over a 24-hour period. If the patient remains asymptomatic, discharge is appropriate. This can be done at an observation level of care. If the patient develops signs of peritonitis or requires operative intervention, this hospitalization can be changed to acute inpatient.

The hospital, through its agent has appealed the denial of acute in-patient services. The MCG (Milliman care guidelines) guideline for "Multiple Trauma" lists clinical indications for admission to inpatient care. Regarding use of criteria for "multiple trauma," the patient in fact did not have multiple trauma but rather an isolated penetrating trauma to the abdomen. Multiple trauma criteria state as alternative treatment--observation in the emergency department in a patient without urgent surgical needs.

General Admission criteria cited are that the patient required vital sign checks more than every 4 hours, and that cardiac and respiratory monitoring was beyond the scope (e.g., > [greater than] 24 hours) of observation care. The specific criteria cited are that the patient required surgical evaluation, cardiac monitoring, pulse oximetry, and hemodynamic monitoring, maintained NPO (nothing by mouth), serial abdominal exams, wound care, monitoring for bleeding, intravenous fluids and pain management. According to the cited Milliman Guideline (General Admission Criteria), vital signs, neurologic signs, or vascular checks more frequently than every 4 hours was not required even if vitals were recorded more frequently. Vital sign checks for floor (non-ICU [intensive care unit]) admission can be rendered at a lower level of care (e.g. observation).  Cardiac or respiratory monitoring beyond scope (e.g., over 24 hours) of observation care was not required and actual hospital stay was less than 24 hours. The patient did not require pulmonary artery catheter monitoring, there was no suspected compartment syndrome, cerebral bleeding, hydrocephalus, or vasospasm monitoring, or suspected increased intracranial pressure or need for cerebral edema monitoring.

The appeal notes the patient could not have been safely managed at a lower level of care or in the outpatient setting. No reason is given why the care rendered was not available at a lower level of care.  The care rendered at an observation level of care would have been identical to that which was rendered without compromise of the quality of care or patient safety.