Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head injury. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient was a male with a history of asthma. He was admitted after a head injury causing a concussion.  Earlier that day, he was running while playing tag, and he ran into a pole, hitting his head and falling. There was no loss of consciousness. He vomited three times afterwards. 

The patient went to an emergency room, where his Glasgow coma scale was 15.  He had a normal head CT (computed tomography). He was transferred to another facility and admitted for further monitoring. On arrival, he had a small hematoma in the left forehead and a normal neurological exam.  The admitting physician documented that inpatient level of care was required and that it would last at least two midnights.  The history included the child having a headache that resolved by the time of admission. He had no complaints related to asthma.  Further evaluation included a complete blood count which showed 15,000 leukocytes with elevated neutrophils at 90% and platelets were elevated at 503,000. A basic metabolic panel was unremarkable. 

The patient was treated with intravenous fluids, as needed Zofran and Tylenol, and neuro checks every 4 hours.  He remain stable and was discharged home the following day. 

The inpatient admission was denied by the plan as not medically necessary arguing the care could have been provided at an emergency room or observation level of care. This decision was appealed by the treating provider, arguing that he required inpatient care to monitor for delayed sequelae of the head injury. This review is in regards to the inpatient stay. 

No, the Inpatient admission was not medically necessary. 

The standard of care for the evaluation and management of mild traumatic head injuries in children is guided by published PECARN (Pediatric Emergency Care Applied Research Network) criteria (Lumba-Brown, Babl, Atabaki).  The initial step in management is deciding whether or not neuroimaging is indicated.  Afterwards, the disposition of each case depends on the clinical situation.  Generally, observation for 4 to 6 hours is found to be effective in cases of up to intermediate risk and cases where imaging is not completed. 

In this case, the patient had a PECARN (Pediatric Emergency Care Applied Research Network) calculated risk of CITBI (clinically important traumatic brain injury) of 0.9%. 

The definition of CITBI (clinically important traumatic brain injury) is as follows: 
1) Death from TBI (traumatic brain injury), 
2) Neurosurgery, 
3) Intubation for more than 24 hours for TBI (traumatic brain injury), or 
4) Hospital admission of 2 nights or more associated with TBI (traumatic brain injury) on CT (computed tomography). 

The patient's mechanism of injury was relatively mild.  He was at intermediate risk due to self-limited vomiting.  Given the low risk of CITBI (clinically important traumatic brain injury) and generally mild mechanism of injury, the child could have been discharged home after the normal head CT (computed tomography) or managed in observation status.  A 4 to 6-hour period is generally accepted as sufficient in low to low risk to intermediate risk cases, but an overnight observation would also be reasonable given the repeated vomiting.  Therefore, the patient could have been safely managed in observation level care, and thus admission level care was not necessary. 

The health plan provided an argument that the patient did not require acute and patient level care. They argued that the patient could have received care in the emergency room or in observation of care. This determination is in accordance with currently excepted standards of care as discussed above. Therefore, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.