Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Broken Wrist. 
Treatment: Inpatient admission. 

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

The patient is a male that allegedly (initially) fell six feet hitting his head and left arm 
on the wooden porch below. The story around the fall was questionable and there 
were differing stories between the injured patient and his Mother. The patient 
denied that he had fallen. The Mother reported no loss of consciousness but "he 
was not acting right." The Mother in fact encountered the injured patient listening to music with headphones and noted a deformity of his wrist. The patient was taken by 
his Mother to the emergency department where he was a Level II trauma activation. 
On arrival, vital signs were normal except for mildly low systolic blood pressure of 
97 millimeters of mercury (mmHg). The patient was alert and oriented (Glasgow Coma Score of 15). His only complaint was left wrist pain. Physical examination 
showed a left wrist deformity. X-ray of the left wrist showed a distal radius and ulnar 
fracture. The patient was administered medication for pain. 

The Trauma Surgeon states, "with GCS (Glasgow Coma Score) =15, normal mental 
status, and no palpable skull fracture, the patient lacks high risk factors for clinically 
important traumatic brain injury." The mechanism of injury and reported behavioral 
change were cited as a 0.9% risk of traumatic brain injury which prompted obtaining 
a computed tomography (CT) of the head. CT (computed tomography) of the head 
showed no intracranial injury. Preliminary report noted mild left frontal scalp 
swelling outside the skull. Final report did not even mention the frontal scalp 
swelling. Psychiatry consult and urine drug screening were recommended but the 
parents refused (the patient in fact had a drug screen on admission which was 
negative for drugs or alcohol). The wrist fracture underwent attempted reduction 
under conscious sedation with hematoma block in the emergency room (ER). The 
reduction was inadequate. The patient was admitted to acute inpatient level of care. 
The following day the patient was taken to the operating room (OR) by Orthopedic 
Surgery for closed reduction and splinting of the fracture with a sugar thong splint. 
Good alignment was attained without need for open incision with internal fixation. 
The patient was evaluated in the post-anesthesia care unit (PACU) and reported no 
pain. Orthopedics signed off and recommended outpatient follow-up. The patient was transferred to Pediatrics for further workup given the conflicting history 
surrounding the event. Electroencephalogram (EEG), magnetic resonance image 
(MRI), and cardiac evaluations were ordered. Video electroencephalogram (EEG) 
was performed overnight which showed no seizure activity. 

The hospital, through its agent states inpatient level of care was required for 
management of fall, head injury, altered mental status, questionable syncopal 
episode, and left wrist pain / deformity. The patient required continuous neurological 
monitoring and pain control. It is stated "the patient was at risk for multiple 
complications including compartment syndrome, amputation, subdural hematoma, 
subarachnoid hemorrhage, epidural hematoma, concussion, status epilepticus, 
continued falls / trauma, even death." The hospital's agent states the care could not 
have been done in an outpatient setting and cites Milliman Care Guidelines for 
"Ambulatory Surgery Exception" and "Syncope." 

No, the treatment, acute inpatient admission, was not medically necessary. The 
patient could have been cared for at a lower level of care than acute inpatient. 

Based on the information known to the Surgeon based on the evaluation, the 
patient did not require acute inpatient care. The care rendered was all consistent 
with a lower level of care. Neither of the injuries warranted acute inpatient level of 
care. The following day the patient was transferred to Pediatrics for further workup. 
Electroencephalogram (EEG), magnetic resonance image (MRI) and cardiac 
evaluations were ordered. The results of the electroencephalogram (EEG) showed 
no seizure activity. All this evaluation could have been done within the framework of 
a lower level of care than acute inpatient. The care the child would have received 
at a lower level of care e.g. observation would have been identical to that which he 
in fact received. 

In response to the hospital appeal through its agent, that inpatient level of care was 
required for management of fall, head injury, altered mental status, questionable 
syncopal episode, and left wrist pain / deformity. None of these findings necessarily 
require acute inpatient level of care. It is unclear whether the patient sustained a fall 
and there was no signs of a head injury or altered mental status. Reduction of the 
wrist fracture even with open reduction / internal fixation (which was not required) is 
an outpatient procedure. The hospital's agent states the patient required continuous 
neurological monitoring and pain control. Continuous neurological monitoring was 
not required for a patient with normal mental status and negative 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 e.g. 
observation. Review of the records note the patient required minimal medication for 
pain control. Records show the patient received only a single dose of morphine in 
the emergency room (ER), single dose of hydromorphone and a single dose of 
Toradol (ketorolac) for pain during his hospitalization in addition to non-steroidal 
anti-inflammatory medication. The hospital agent further states, "the patient was at risk for multiple complications including compartment syndrome, amputation, subdural 
hematoma, subarachnoid hemorrhage, epidural hematoma, concussion, status 
epilepticus, continued falls / trauma, even death." The risk of these enumerated 
complications is not commensurate with the injuries and is grossly exaggerated. 
Regarding compartment syndrome and amputation, closed reduction of a forearm 
fracture is minimal to non-existent risk. The risk of developing a brain bleed with a 
normal head computed tomography (CT) and normal mental status throughout the 
hospitalization is overstated. The hospital's agent states the care could not have 
been done in an outpatient setting and cites Milliman Care Guidelines for 
"Ambulatory Surgery Exception" and "Syncope." 

Regarding Ambulatory Surgery Exception "severity of disease," as outlined above, 
the severity of disease (identified injuries due to trauma) did not warrant an 
exception to ambulatory level of care. The patient did not require an emergent 
procedure as the procedure was deferred until the following day for convenience of 
the surgeon and hospital. There were no perioperative events which required 
prolonged care. 

Regarding Syncope causing injury requiring hospitalization as indication for 
inpatient care, there is nothing more than a suspicion based on inadequate history 
that the patient had a syncopal event leading to the injury and that the injury was 
nothing more than an accident. The treatment / monitoring precipitated by the injury 
did not require an inpatient level of care. It could have been rendered at a lower 
level of care without compromise of the quality of care rendered or patient safety.