Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a female with a past medical history significant for Meniere's disease who presented to the hospital after she sustained a fall. The patient slipped on ice and landed on steps. Following the fall, she presented to the emergency department where she was diagnosed with multiple thoracic and lumbar transfers process fractures. She was seen by the trauma surgery team. Subsequently, she came back with complaints of increasing back pain that was unrelieved with analgesics. The patient denied bladder or bowel dysfunction or shooting pain in the lower extremities. The computed tomography (CT) scan of the lumbar spine that was performed on the day of admission demonstrated fractures of the 11th and 12th thoracic vertebra as well as a 1.7 centimeter (cm) splenic laceration.
When the patient was seen by the admitting physician, she was afebrile. Her pulse rate was 78 beats per minute (bpm), respiratory rate was 18 breaths per minute, blood pressure was 113/58, and oxygen saturation was 96% on room air. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. There was tenderness in the posterior lower left side of the chest. There was mild tenderness in the left upper quadrant without guarding or rebound. The patient was able to move all four extremities. Motor function and sensation were grossly intact. There was lower thoracic and lumbar tenderness appreciated with no cervical spine tenderness. The patient was admitted to the hospital and multimodal pain control was initiated. The patient was started on a regular diet and was recommended to utilize an incentive spirometer.
On the next day after the day of admission, it was reported that the patient had no new complaints. The pain improved, and the patient denied shortness of breath. The patient remained afebrile and hemodynamically stable. The oxygen saturation was 96% on room air. The laboratory evaluation revealed that the white blood cell count was 4.9, hemoglobin was 11.8, hematocrit was 36.8, and platelets were 152. The sodium was 140, potassium was 4.2, chloride was 110, bicarbonate was 25, blood urea nitrogen (BUN) was 20, creatinine was 0.8, and glucose was 89.
According to the medical records, the patient was followed by the surgical service who stated in the progress note that the patient's pain was well-controlled. The hemoglobin remained stable. Therefore, the patient was cleared for discharge by the trauma surgery team.
At issue is the medical necessity of the Inpatient Stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
Overall, the patient remained in stable clinical condition. Her pain was well-controlled within a short period of time after admission, and she was able to transition to oral pain medications. The review of the medical records demonstrated that despite the injuries that the patient sustained as a result of the fall, she remained hemodynamically stable. Her pain became well-controlled within a short period of time after admission. This patient did not need any interventions or diagnostic studies requiring admission at the acute inpatient level of care. Despite spleen laceration, the patient's hemoglobin remained stable, and she had no significant bleeding requiring intervention.
Taking into consideration all these facts, and given the clinical circumstances, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.