Appeal type: Medical necessity
Decision: Upheld

Diagnosis: nasal bone fractures

Treatment: hospital admission

The insurer is denied coverage for hospital admission

The denial is upheld. 

This male patient has a history of Wolff-Parkinson-White syndrome (WPW), anxiety, depression, liposuction, status post ablation 10 years prior.

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. The patient did not meet criteria based upon MCG guidelines as noted by the insurer as well as noted below. 

MCG Health noted in General recovery care 25th edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: Hemodynamic instability; Hypertension requiring inpatient  treatment; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern;  Severe heart failure;  Severe respiratory findings; Severe airflow or ventilation abnormalities; Impending or actual respiratory arrest; Neurologic abnormalities; New-onset severe neurologic findings; Suspected acute intra-abdominal process; Severe physiologic disorder; Abdominal abnormalities; Acute renal failure; Significant uremic complications; High fever or other high-risk infection situation: Temperature less than 95 degrees F (35 degrees C) (rectal); Severe electrolyte abnormalities requiring inpatient care; Acute blood loss causing significant abnormality; Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; Severe adverse drug or systemic toxin reaction requiring inpatient treatment; Severe pain requiring acute inpatient management: Severe malnutrition as indicated by 1 or more of the following: Estimated nutritional intake of less than 25% of calculated energy needs, Body mass index of less than 18.5, Body mass index of less than 20 and unintentional weight loss of 5% or more of usual body weight; Severe behavioral health issues; Inpatient monitoring  needed; Treatment requiring inpatient care; Emergency procedures needed. Based upon these guidelines this patient could have been observed rather than an acute admission as he did not have any indication as noted above for inpatient stay.

In addition, as per MCG Health Guidelines General recovery care 25th Edition: Multiple trauma GRG: PG-MTR (ISC GRG) Hospital admission is indicated when patient with significant multiple trauma requires inpatient care for 1 or more of the following: Major surgical and post procedural care; Nonoperative care of significant injury; multiple trauma and one or more general admission criteria. MCG notes that alternatives to admission include: Outpatient care in emergency department, rapid treatment site, or urgent care center, X-rays and wound care as indicated, Surgical evaluation, Diagnostic testing (e.g., CT scan, ultrasound), Observation of patient without urgent surgical requirements, Repeat testing (e.g., hematocrit, ultrasound); Home care: Wound care, Facilitation of specialty follow-up, Physical therapy. This patient could have been treated in an outpatient care status with observation rather direct inpatient admission. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.
The carrier's denial of coverage for hospital admission is upheld.  The medical necessity is not substantiated.