Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head Injury
Treatment: Inpatient admission
The insure denied the inpatient admission.
The denial is upheld.

The patient is a male child that fell from a high bed hitting the right side of his head on a ceramic floor. There was no loss of consciousness or vomiting. The child cried immediately after the fall. There was reported bleeding and swelling of the right ear. Physical examination showed ecchymosis and edema in the right posterior auricular area with dried blood. No acute bleeding was present. The patient had normal mental status for age and normal vital signs.

CT (computed tomography) of the head done showed no skull fracture. Findings were fluid in the mastoid sinus cells and trace subcutaneous emphysema. There was the possibility of an occult fracture in the region of the right mastoid bone. Trauma team recommended admission for "observation."

The patient was admitted to acute inpatient level of care.

Otorhinolaryngology (ENT) saw the patient and recommended ear drops in the affected ear for 10 days. The patient was discharged home later that day.

The acute inpatient level of care was denied as not medically necessary. This is a review for an appeal of the previous denial.

The hospital through its agent has appealed the denial of the acute inpatient level of care. The basis of the appeal was that inpatient admission was medically necessary because of concern for "acute trauma-related head injury," and that the care rendered could not have been done in the outpatient setting.

No, the Inpatient admission was not medically necessary, as the patient could have been cared for at a lower level of care.
The patient is a male that reportedly fell from a high bed onto a ceramic floor striking the right side of his head. The child did not lose consciousness, cried immediately and did not vomit. There was bleeding from the right ear. The patient was taken by ambulance to the hospital. On arrival vital signs were normal and the child had normal mental status for age. Physical examination showed swelling and ecchymosis behind the left ear.

CT (computed tomography) of the head done showed no skull fracture. Findings were fluid in the mastoid sinus cells and trace subcutaneous emphysema. There was a probability of an occult fracture in the region of the right mastoid sinus. Trauma surgery recommended admission to Pediatrics for "observation." ENT (otolaryngology) saw the patient later that day and recommended 10 days of ear drops.

Based on the information available at the time of admission, the patient did not require acute inpatient care. The care rendered was consistent with and could have been rendered at a lower level of care. Later that day, the patient was discharged home. The care the child would have received at a lower level of care would have been identical to that which he in fact received.

Yes, the health plan acted reasonably with sound medical judgment without compromise of the safety of the patient in the denial of the acute inpatient level of care.
The patient is a male child that presented after fall striking his head. On arrival the child had normal mental status and normal vital signs. CT (computed tomography) of the head showed no intracranial injury and the probability of an occult fracture of the mastoid. Neurological monitoring or observation for minor head trauma or skull fracture does not require acute inpatient level of care with a negative CT (computed tomography) scan of the brain. The child could have been treated at a lower level of care without compromise to the quality of care rendered or patient safety. The care that the child would have received at a lower level of care would have been identical to that which he in fact received.

Isolated skull fractures in children do not require inpatient admission. The need for admission in children with isolated skull fractures without brain injury or suspected child abuse is not considered medically necessary. Most can safely be discharged from the Emergency Department.  A 10-year retrospective study of isolated traumatic skull fractures and normal neurological examination analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention. Seventy-one patients presented with acute isolated skull fractures. Their ages ranged from 1 week to 12.4 years old. The minority (22.5%) of patients were discharged from the ED (emergency department) following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation. No patients underwent repeat head imaging during their index admission. The authors concluded, "Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED [emergency department] without inpatient observation."

Another study retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for non-displaced skull fractures at a single children's hospital between January 2009 and December 2013. Three hundred twenty-six patients met inclusion criteria. The median patient age was 19 months (range 2 weeks to 15 years). One hundred eighty-four patients (56%) were placed under 23-hour observation, 87 (27%) were admitted to the hospital, and 55 patients (17%) were discharged from the emergency department. The mean hospital stays for patients admitted to the hospital was 46 hours (range 7-395 hours). The mean hospital stays for patients placed under 23-hour observation status was 18 hours (range 2-43 hours). The reasons for hospitalization longer than 1 day included Child Protective Services involvement in 24 patients and other injuries in 11 patients. Thirteen percent had altered mental status or loss of consciousness by history. No patient had any neurological deficits on examination, and none required neurosurgical intervention. Less than 16% had subsequent outpatient follow-up. These patients were all neurologically intact at the follow-up visit. The authors concluded, "Hospitalization is not necessary for many children with non-displaced skull fractures. Patients with mental status changes, additional injuries, or possible non-accidental injury may require observation."

A meta-analysis reviewed fourteen articles to collect data on admission rates, outcomes, and necessity of neurosurgical intervention in isolated skull fractures in children. Admission rates ranged from 56.8% to 100%; however, only 8 of more than 5000 patients developed new imaging findings after admission, all of which were nonsurgical. Only 1 patient required neurosurgical intervention for a finding evident upon initial evaluation.

The authors concluded "pediatric isolated skull fracture patients with a presenting Glasgow Coma Scale score of 15 who are neurologically intact and tolerating feeds without concern for nonaccidental trauma or an unstable social environment can safely be discharged following ED [emergency department] evaluation to a responsible caregiver."

In response to the hospital appeal through its agent that inpatient level of care was required because of concern for "acute trauma-related head injury," and the care could not have been rendered in the outpatient setting.  This is not consistent with the overwhelming medical literature for isolated skull fracture. Continuous neurological monitoring is not required for a child with normal mental status and negative CT (computed tomography) scan of the brain. There is no mention by the hospital's agent as to why these same interventions were not available at a lower level of care.