Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wrist fracture, Vertebrae fracture. 
Treatment: Inpatient Admission. 

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

The patient is a male. He presented to the Emergency Department by ambulance to  after sustaining a fall from a ladder from a height of six feet. Emergency Medical Services (EMS) reported systolic blood pressure in the 90s in the field. The patient fell on his feet and did not hit his head. The patient complained of back and right wrist pain. 

Computerized tomography (CT) scan of the patient's abdomen and pelvis was negative for injury. CT scan of the chest showed an anterior compression fracture of the T-12 (thoracic 12th) vertebrae. X-ray of the right wrist showed a fracture dislocation of the radial head. Neurosurgery evaluated the patient for the spine fracture and recommended a thoracic-lumbar-sacral orthotic (TLSO) brace when out of bed. The patient was admitted to acute inpatient level of care. 

The patient was taken to surgery by Orthopedic Surgery for open reduction and internal fixation of the right wrist. 

Progress Note states the patient was doing well. Physical Therapy/Occupational Therapy was to see the patient. Pain was controlled and the patient was tolerating a diet. Physical Therapy saw the patient. He had his thoracic-lumbar-sacral orthotic (TLSO) brace delivered and was cleared for discharge. The patient was discharged home. 

Follow-up radiology reports are provided, though not relevant to the questions in this review: 

Magnetic resonance imaging (MRI) scan of the thoracolumbar spine showed a compression fracture with 20% loss of height of the anterior T-12 vertebrae. There was no significant spinal canal stenosis at the level of the fracture and no evidence of spinal cord injury. 

The patient had a follow-up computed tomography (CT) scan of the right wrist which showed an ulnar bone fragment with developing non-union and possible impingement of one of the fixation pins into the radiocarpal joint space. 

The acute inpatient level of care was denied by the health plan as not medically necessary, since they assert that the care could have been rendered at a lower level of care. This review is pursuant to an appeal of the denial of the acute inpatient admission. 

No, the Inpatient Admission was not medically necessary. 

The patient is a male that presented to the Emergency Department by ambulance after sustaining a six-foot fall from a ladder. The patient did not hit his head or report loss of consciousness. There was reported systolic blood pressure in the 90s in the field. 

On arrival, the patient was hemodynamically stable with normal vital signs. The patient was neither tachycardic nor hypotensive throughout his hospital stay. The patient complained of back and right wrist pain. The patient underwent imaging which revealed a T-12 (thoracic 12th) vertebrae compression fracture. X-ray of the right wrist showed a fracture dislocation of the radial head. The patient's wrist injury was treated by open reduction and internal fixation, which would be considered an outpatient procedure. Compression fracture of a single vertebrae of the anterior thoracic spine is considered a stable fracture. Anterior compression fractures of the thoracic spine (single column) do not require operative fixation and are treated with a thoracic-lumbar-sacral orthotic (TLSO) brace as was ordered. Neurosurgery evaluated the patient for the spine fracture and recommended a (TLSO) brace when out of bed. Thoracic-lumbar-sacral orthotic (TLSO) brace was delivered and the patient was out of bed with Physical Therapy. Pain was controlled and the patient was tolerating a diet. 

Physical Therapy cleared the patient. 

The care rendered did not require an acute inpatient level of care. The patient could have cared for at a lower level of care. 

The patient presented after sustaining a fall from a height of six feet. The patient presented as a trauma activation and underwent evaluation in the Emergency Department. The patient was always hemodynamically stable. He was evaluated in the Emergency Department including computerized tomography (CT) scans of the chest, abdomen, and pelvis. He had x-rays of his right wrist which showed a fracture dislocation of the radial head. Computerized tomography (CT) scan of the chest and abdomen identified an anterior compression fracture of the T-12 (thoracic 12th) vertebrae. The patient underwent operative repair of the right wrist fracture. 

Operative repair of this type of fracture does not require inpatient level of care. Regarding the thoracic fracture, an anterior wedge (compression) fracture is a stable fracture and only requires a thoracic-lumbar-sacral orthotic (TLSO) brace. In stable fractures of the thoracic spine treated with thoracic-lumbar-sacral orthotic (TLSO) bracing, patients are followed with radiographic imaging to ensure bony union across the fracture site. 

The hospital's agent cites InterQual criteria for admission citing a finding of a thoracic spine fracture. However, the criteria specifically exclude uncomplicated compression fractures which is the specific injury which the patient suffered. The patient's identified injuries and care did not require an acute inpatient level of care. The patient could have been treated at a lower level of care without compromise of patient safety or the quality of care rendered.