Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest wall pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld .


This is the case of an adult patient with a past medical history of breast cancer status post mastectomy who presented to the emergency department (ED) with complaints of chest wall pain. The patient presented to the triage nurse with stable vital signs and mid chest bruise, tender to touch with slight swelling of the right side of her chest. Lung sounds were equal and clear.  Respirations were unlabored. 

The emergency department (ED) provider noted that the patient complained of pain after falling. She denied hitting her head, headache; loss of consciousness (LOC). Vital signs were stable with heart rate of 71 bpm(beats per minute) and Blood Pressure 134/69 mmHg(millimeters of mercury). Examination revealed breath sounds equal bilaterally with small area of tenderness and ecchymosis over the sternum without rib tenderness. Labs were ordered including troponin, X-ray of the chest, Chest computed tomography (CT), X-ray of the sternum and electrocardiogram (EKG). Troponin was normal.

Trauma consult was obtained and noted that the patient had worsening pain. Respiratory parameters were normal. electrocardiogram (EKG) and troponin were normal. Sonogram was negative. The initial recommendations were telemetry unit admission for observation of sternal fracture, pain control and rib fracture protocol. The attending noted concern for blunt cardiac injury; patient to be placed in tele monitoring in observation. If after a short period of time the pain is controlled, electrocardiogram (EKG) is normal.

Chest X-ray was negative except for non-displaced sternal fracture in the superior aspect of the body of the sternum. Computed tomography (CT) of the chest showed non-displaced fracture of the sternum, otherwise unremarkable.

The patient could have been observed as per the notes in observation and sent home without an inpatient level of care admission. There was no indication for telemetry admission. She did not have any rib fractures or flail chest. She had a non-displaced sternal fracture. She did not have a pneumothorax or effusion. 

As per Milliman Care Guidelines (MCG) Health General recovery care 27th Edition: musculoskeletal disease, hospital admission is needed for appropriate care of the patient because of 1 or more of the following: Bone, joint, muscle, or orthopedic device infection (e.g., periprosthetic infection that requires inpatient care; Vertebral fracture that requires inpatient care (MEDICAL); Nonvertebral fracture, dislocation, or other musculoskeletal injury that requires inpatient care as indicated by Compartment syndrome (proven or cannot be ruled out during observation care), Major injury requiring inpatient care (nature of injury necessitates inpatient treatment or monitoring), severe pain requiring acute inpatient management; Rheumatologic disease (e.g., systemic lupus erythematosus, rheumatoid arthritis, spondylarthritis) exacerbation or related finding that requires inpatient care; Vasculitis with complications or findings that requires inpatient care; Severe crystal arthropathy (e.g., gout, pseudogout) that requires inpatient care; Rhabdomyolysis that requires inpatient care; Myopathy that requires inpatient care; Postamputation complication that requires inpatient care; severe pain requiring acute inpatient management due to musculoskeletal condition. 

This patient did not require inpatient admission based upon these criteria. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient level of care hospital admission is not substantiated.