Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries.

Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with no past medical history who presented to the emergency department (ED) with complaints of a stab wound in his back. He reported that he was at a party and his friend was in an argument with someone who pulled out a knife. ED triage note indicated the patient complained of stab wound to the back. The history of present illness (HPI) indicated a single 4 centimeter (cm) stab wound to the middle back, 2 inches lateral to midline on the right side. The primary survey indicated the airway intact, and the patient was able to speak clearly; there were bilateral breath sounds. There was a 4 cm wound to the right side just below the costal margin: 2 inches lateral to spine, actively bleeding. Computed Tomography (CT) of the abdomen showed a laceration at the level of the right flank extending into paraspinal musculature with subcutaneous hematoma. There was active extravasation into the right paraspinal area. There was no intrathoracic or intra-abdominal extension. The plan was to admit to trauma surgery. The wound was closed at the bedside. The patient was monitored and the following morning no active bleeding was noted. The patient's hematocrit (Hct) was stable.

Based upon the information provided, the hospital inpatient admission is denied as the patient could have been treated on an observation status without an acute inpatient admission as this procedure laceration repair of the musculoskeletal bleed is considered an ambulatory procedure. The patient did not meet criteria based upon Milliman Care Guidelines (MCG) as noted by the insurer, as there were no associated risk factors that would have necessitated inpatient surgery. MCG Health Guidelines General recovery care 25th Edition: Cardiovascular surgery or procedure notes that the Operative Status Criteria is Ambulatory for procedures such as: Electrophysiologic studies with or without ablation, Pacemaker placement, Angioplasty, Cardiac catheterization, Angiography, Non-aortic endovascular repair, Vascular access placement, repair, or removal, Simple vascular repairs, Simple arteriovenous fistulas (e.g., for dialysis access). Thus, for a procedure such as this where there is simply a ligation of bleeding muscle, ambulatory status is sufficient with a 23 hour observation. Thus, this patient only required observation status and not an inpatient stay. 

In addition, MCG Health Guidelines General recovery care 25th Edition: Musculoskeletal surgery or procedure notes that the Operative Status Criteria is ambulatory for procedures such as: Closed or open reduction of simple fractures, Simple internal fixations, Simple external fixations, Simple wound repairs, Plastic operations on tendon or joints, Bone biopsies, Removal of most orthopedic devices. Thus, even using these guidelines the patient did not require inpatient admission but rather a 23 hour observation. The patient was in the hospital for less than 23 hours and did not require inpatient admission. He did require care, but this could have been done with a 23 hour observation status and not an acute inpatient admission.

Finally, MCG Health Guidelines General recovery care 25th Edition: Multiple trauma notes that hospital admission is indicated when patients with significant multiple trauma requires inpatient care for 1 or more of the following: major surgical and post-procedural care, non-operative care of significant injury. This patient did not meet any of the criteria as he only needed observation as he did not have a significant injury requiring inpatient status.

The health care plan did act reasonably and with sound medical judgment. 

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.