Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right ankle pain, left thigh pain, tingling in neck after bicycle accident
Treatment: Inpatient admission

The Inpatient admission was not medically necessary. The patient's care could have been rendered at a lower level of care.

The patient is a male that was struck by a car. He landed on the hood of the car on the right side of his body. There was no loss of consciousness. He arrived in the late evening by ambulance complaining of right ankle pain, left thigh pain and tingling in the neck. Physical examination showed neck pain while turning his head, right ankle swelling, bilateral abrasions over the malleoli, ecchymosis over the right shoulder, and tenderness over the left greater trochanter. All the extremity x-rays were negative for fracture. The patient was ordered for an MRI of the spine to rule out a ligamentous injury. The MRI was ordered for the evening of presentation, but was not done until that afternoon (approximately 15 hours later), because the patient's mother was unavailable to sign the safety form. 

The patient had normal vital signs (the hospital states the patient was tachycardic with a pulse rate of 100 bpm which would be considered normal for a patient of that age). No significant injury was identified from the work-up. Admission orders included oral analgesia and regular diet which was discontinued later presumably in anticipation of the MRI. The patient had the collar removed and was discharged soon after the MRI was completed, ruling out a neck injury. 

The acute inpatient level of care was not medically necessary for this child's 19 hour hospitalization. The care that the child would have received at a lower level of care, e.g., observation in the ER or ward, would have been identical to that which he in fact received. 

The patient is a male that was struck by his bicycle in the afternoon / evening. He was brought to the Hospital by ambulance in the evening. The child was evaluated in the ED including labs, x-rays, and physical examination. No bony injury was identified. The patient complained of neck pain and the neck could not be cleared. An MRI was appropriately ordered to rule out a ligamentous injury. This could have been done in the evening / early morning, but because of the absence of the patient's mother to sign the safety form, it was not done until the late afternoon the next day. Pending the MRI and without identification of any other significant injury which required hospitalization, the patient could have been observed without need for acute inpatient level of care. 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, e.g., observation in the ER or ward, would have been identical to that which he in fact received.

In response to the hospital appeal through its agent citing that the physician exercised an expert opinion for admission out of concern that the symptoms were attributed to an acute or escalating clinical condition. The patient was not seen or evaluated by the Attending admitting physician until the following morning and never specifically indicated the need for acute inpatient level of care. The admission to inpatient was ordered by the Surgery Resident and not based on specific direction from the attending surgeon or based on the gravity of the patient's condition. The hospital's agent states the child was tachycardic on arrival (pulse rate was 100 bpm). In response, a normal pulse rate in a patient of this age according to Advanced Trauma and Life Support for the pediatric patient is < 120, and 100 even in an adult would be the lowest number that would be considered tachycardia.  The following injuries are mentioned: neck pain while turning his head, right ankle swelling, bilateral abrasions over the malleoli, ecchymosis over the right shoulder, and tenderness over the left greater trochanter. Bruises and abrasions do not require inpatient level of care. The only potential injury which would require acute inpatient care would be a demonstrated neck injury, which was ruled out by the MRI. The hospital's agent states the patient required acute inpatient monitoring, but fails to address which part of the monitoring required inpatient care. The primary reason for the child's ongoing evaluation was to clear the cervical spine. Cervical spine precautions pending studies to rule out an injury would not require inpatient monitoring.