Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental delay, acute left eye pain, swelling, bleeding. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

This is a young male with a history of developmental delay who presented with acute left eye pain, swelling, bleeding, and vision loss after a high velocity projectile injury with BB (ball bullet) gun shooting. There was concern for acute traumatic left globe rupture, large corneal laceration, and vision loss based on computed tomography (CT) imaging. Prompt therapy with intravenous antibiotics had to be initiated. The patient required emergent ophthalmologic surgery with ruptured globe repair followed by very close inpatient monitoring. This way, a more viable follow-up treatment plan could be formulated, and morbidity and mortality could be prevented. All of this could not have been done in the outpatient setting. This patient could not have been managed at a lower level of care due to the acuity of his presenting illness, need for inpatient interventions including intravenous and topical antibiotics and emergent ophthalmologic surgery, and high risk for clinical complications including persistent bleeding, secondary infection like endophthalmitis, and permanent vision loss. Based on the Milliman Care Guidelines, this patient met several criteria for acute inpatient hospitalization. This patient presented with severe left eye pain, swelling, bleeding, and vision loss secondary to high velocity projectile trauma caused by BB (ball bullet) gun shooting in the park. Due to the severity of his acute trauma-related ophthalmologic injuries including globe rupture, large corneal laceration, and retained foreign body, the patient was at very high risk for life-threatening complications. Therefore, he required acute inpatient management with emergent surgical and medical management. He required emergent ophthalmologic surgery with ruptured globe repair as well as intravenous and topical antibiotic therapy. This is a young boy who was shot in the left eye with a BB (ball bullet) gun with dark drainage and swelling of the eye and was seen at the Medical Center. The patient was admitted for open globe of the left eye with a large corneal laceration extending to the sclera, intraocular foreign body in the vitreous, and aqueous leak. The patient underwent ruptured globe repair of the left eye and TobraDex, ciprofloxacin, and prednisolone drops were started. The patient was instructed to use oral antibiotics as well. intracameral antibiotics were administered for endophthalmitis prophylaxis alongside subconjunctival steroids in the operating room. The authorization for the above referenced date of service has been denied by the health plan for lack of medical necessity. The provider asserts the necessity for inpatient admission on this service date. 

The proposed treatment was medically necessary. 
In the setting of ruptured globe, corneal scleral laceration repair is absolutely indicated. Compromise of the globe with an opening to the external environment puts the patient at risk for endophthalmitis as well as seeding of the bacteria into the circulation. Surgical repair along with intracameral, topical, and intravenous antibiotics are indicated to prevent endophthalmitis and sepsis. This type of repair was followed by close observation under admission standard of care. The vital signs must be monitored on a regular basis and blood draws must be conducted to rule out sepsis.