Appeal type: Medical necessity
Decision: Upheld

Diagnosis: neck and back pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission 
The denial is upheld 

This is the case of an adult with no significant medical history who presented to the emergency department (ED). As per the trauma History and Physical the patient presented following a fall. She was drinking alcohol the night prior. She fell down 15 steps. She did not remember falling or the events of the fall. She woke up with difficulty moving her left arm, pain to the left arm, and pain over the back and neck. She awoke sober and was concerned causing her to come to the ED. On exam the airway was intact. E- FAST (Extended Focused Assessment with Sonography in Trauma) was negative. She appeared in no acute distress with vital signs normal. There was some cervical (C) spine tenderness with C collar in place. The neurological exam was intact. A Chest x-ray (CXR) and pelvic x ray revealed no evidence of a considerable fracture. Labs revealed a White blood cell count (WBC) of 12.3. The patient was admitted with a questionable fracture of the left maxillary second premolar shown on a computed tomography (CT) with the rest of the imaging negative.

Labs and x-rays were included and reviewed. Of note was that the CT of the cervical spine showed no evidence of acute injury to the cervical spine. The spine was therefore cleared. A Magnetic resonance imaging (MRI) was done and also showed a normal cervical spine. The patient was discharged.

In addition, as noted by MCG (Milliman Care Guidelines) General Recovery care 26th edition Musculoskeletal surgery or procedure GRG (General Recovery Care guidelines): Surgery or other procedures covered by this guideline is indicated for 1 or more of the following: Vertebral fracture with evidence of instability or pending instability (neoplastic lesion of spinal column, compression fracture with spinal canal compromise); Osteoporotic vertebral fracture; Cervical spine fracture; Thoracic vertebral fracture; Lumbar vertebral fracture; Thoracic radiculopathy (herniated disk); Thoracic myelopathy (herniated disk); Need for procedure due to thoracic spine tumor; Need for procedure due to thoracic spine infection; Other spinal procedure required; Pelvic fracture; Fracture (other than vertebral, pelvic, or fracture covered specifically in its own guideline), dislocation, or skeletal injury requiring procedure; Tumor requiring resection or biopsy (e.g., of bone, soft tissue); Removal of implanted device needed; Osteomyelitis or other infection requiring bone resection; Limb reconstruction or amputation needed; Fasciotomy needed (e.g., for compartment syndrome); Medial or lateral unicompartmental knee arthroplasty needed; Patellofemoral arthroplasty needed; Ankle arthroplasty needed; Ankle arthrodesis (open) needed; Bone repositioning procedure (e.g., wedge osteotomy, bone augmentation) needed; Minimally invasive sacroiliac joint fusion needed; Procedure required for musculoskeletal congenital or acquired dysfunction. In addition, MCG notes that continued inpatient stay is needed until 1 or more of the following are present: acceptable patient status for next level of care is achieved and ALL of the following are present: Operative site and other wounds acceptable; Temperature status acceptable; No infection, or status acceptable; No blood loss, or problem resolved; Pain and nausea absent or adequately managed; Vascular, soft tissue, and wound status acceptable; Fracture or injury absent or status acceptable; No spinal surgery, or status acceptable; Activity level acceptable; Intake acceptable; No inpatient interventions needed; General Discharge Criteria met. 
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 inpatient admission is not substantiated.