Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Broken arm
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female child with past medical history significant for right indirect inguinal hernia repair that presented to the emergency department with one-week history of right arm/elbow pain. She had fallen from bed and landed on the right arm. The fall was two to three feet to a hard wood floor. She was in the care of a babysitter at the time. She was taken to the chiropractor the next day because of complaints of pain and was told that it was muscular pain. No x-rays were taken. The patient's generalized pain subsided but swelling persisted until five days prior to presentation, and she continued to have pain with arm flexion. The pain was treated with acetaminophen. When asked why the family did not seek further medical care, they replied that she seemed better, and they were busy. 

The patient's vital signs included temperature 36.9, heart rate 91, and respiratory rate 24. Examination was significant for swelling and deformity of the right elbow with decreased range of motion. Orthopedic Surgery was consulted, with suspicion of fracture of the distal end of the right humerus. This was confirmed by x-ray revealing type two supracondylar humerus fractures. Plans were made for closed reduction in the operating room (OR). Pre-op laboratory studies were obtained, she was given a dose of ibuprofen for pain, and was admitted to the Pediatric floor. Administration for Child Services (ACS) was contacted because of delay in care, and she was placed in one to one (1:1) monitoring. Additional admission orders included nothing by mouth after midnight with intravenous fluids for hydration, Social Work consultation, and vital signs every four hours. 

The patient was taken to the operating room the following evening for closed reduction and internal fixation with percutaneous pinning of the right elbow fracture. Post-operatively, the patient was placed in a long-arm cast. Orders included Toradol for pain management. She was deemed stable for discharge, with the Administration for Child Services follow-up at home.

Yes, the proposed inpatient admission is medically necessary.
Supracondylar fractures of the humerus are the most common elbow fractures in children under ten years of age. Severity ranges from type I non-displaced to type III displaced. Improperly managed type III fractures of this type may lead to joint stiffness. Patients are typically taken to the operating room for closed reduction with immobilization. 

This young female child fell from the bed and sustained a supracondylar fracture. She was taken to a chiropractor the following day where the family was reassured that everything was fine, she simply had muscular pain. No x-rays were obtained. The child continued to report pain with movement, but the family did not seek further medical evaluation until a week had passed. X-rays in the emergency deparment revealed a type II (displaced) supracondylar fracture that required surgical management. Because of the delay in treatment despite ongoing symptoms, in conjunction with the family's report of being too busy (as stated in the emergency department), a report was filed with the local child protection agency. The family was allowed to be with the child, but she was placed under 1:1 monitoring. Until safe discharge could be established, she could not be released to the family. Once this had occurred and she had received appropriate surgical management of her injury, she was discharged home with necessary social and surgical follow-up. A lower level of care would not have been safe or appropriate in this case. Acute inpatient admission was medically necessary and consistent with standard of care practices.

No, the health plan did not act in the best interest of the child.