Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld

This is the case of a patient with a history of bipolar disorder, attention deficit hyperactivity disorder (ADHD), and disruptive mood dysregulation disorder who presented to the emergency department (ED) with complaints of head trauma after being struck by a vehicle. As per the history and physical the patent was struck by a vehicle in the street. The patient had no recollection of the event. He presented to the ED alert and awake and with a C (cervical)-spine mobilization in place. Otherwise, he denied severe headache, neck pain, chest pain, abdominal pain and back pain. On exam the patient did not want to cooperate with evaluation. He had bruising and laceration to the right superior and lateral aspect of the orbit. Pupils were reactive and equal. There was no facial asymmetry. Neuro exam was intact.  Heart rate (HR) was 81.  C spine was negative for acute cervical spine fracture or dislocation. Computed tomography (CT) of the head showed no acute intracranial abnormalities; there was a moderate amount of soft tissue air noted anterior to the right orbit. There was a moderate amount of blood within the right maxillary, ethmoid, and sphenoid sinuses. There was right medial orbital wall fracture and probably right lateral maxillary sinus wall fracture. CT of the maxillofacial showed acute fracture associated with the inferior medial wall of the right orbit, and acute fractures of maxillary sinus of which the most inferior fracture component extended into the alveolar bone. A minimally displaced fracture of the orbital apex associated with the right greater wing of the sphenoid bone was also seen. There was multifocal soft tissue swelling consistent with post traumatic contusion. CT of the abdomen showed no intraperitoneal free air or fluid. CT of the chest did not reveal any significant injury. There was right lower quadrant (RLQ) mesenteric contusion with small adjacent amount of fluid.  WBC (white blood count) was 4.5; hematocrit (Hct) was 43. Labs were otherwise unremarkable. In the ED the patient was seen immediately on arrival. Trauma level 2 was called. The patient was admitted to trauma service pediatric floor for serial exam. 

MCG (Milliman Care Guidelines) Health Guidelines General recovery care 26th Edition: Multiple trauma Hospital admission is indicated when patient with significant multiple trauma requires inpatient care for 1 or more of the following: Major surgical and postprocedural 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. 

There was no indication of need for inpatient admission as noted by MCG guidelines. The admission is therefore denied. The health care plan did act reasonably and with sound medical judgment. 

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.