Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall from scooter

Treatment: Hospital admission

The insurer denied coverage for hospital admission

The denial is upheld 

This case involves a male who presented to the Emergency Department (ED) after a motor vehicle accident.  The documentation indicated the patient was driving a scooter when he collided with a brick wall going approximately 40 to 50 miles per hour (mph).  The documentation detailed the patient was wearing a helmet.  The physical examination revealed the patient was awake and alert.  He was agitated and yelling.  The vital signs revealed a blood pressure 148/103 with oxygen saturation in 99%.  Patient's heart rate was 117 beats per minute (bpm).  The documentation does indicate there was a 4 centimeter (cm) laceration to the superior lip.  There was bleeding from the right nostril.  The recommendation was made for multiple laboratory and diagnostic studies.  The patient did undergo imaging of the lower extremities.  There was no fracture identified.  The patient also underwent a chest x-ray revealing an acute left fifth rib fracture.  There was no evidence of acute pelvic fracture or osseous malalignment.  The computed tomography (CT) scan of the head revealed pre-maxillary facial soft tissue swelling with possible midline superficial foreign body.  CT scan of the maxillofacial bones revealed an acute fracture involving the anterior nasal spine maxilla with overlying soft tissue swelling and possible 3 millimeter (mm) superficial foreign body anterior to the maxilla in the midline with possible nondisplaced nasal bone fracture deformity.  The cervical spine did not reveal any acute fracture.  The documentation indicated the patient was treated with Ativan for significant anxiety in the ED.  The patient's laceration to the lip was sutured.  The recommendation was made to admit the patient for further evaluation and treatment.  The documentation indicated he continued to receive treatment and monitoring.  He was recommended to undergo consultations with psychiatry.  Psychiatry did evaluate the patient and there were no immediate needs.  He continued to improve and there were no further significant adverse events.  The patient was discharged with instruction to follow-up.

According to referenced literature, a patient may be admitted to inpatient services if there is a need for a major procedure.  Additionally, if the patient has symptoms of multiple traumas, and meets the inpatient admission criteria they may be appropriate for an inpatient admission. If a patient has evidence of hemodynamic instability, significant respiratory or cardiovascular findings, evidence of new neurologic abnormalities, or indication the patient requires inpatient monitoring, they may need an escalation of care.  

The documentation indicated the patient was brought to the ED after hitting a wall while driving the scooter.  The documentation does indicate on initial examination the patient had elevated blood pressure with a heart rate of 117.  There was a laceration to the lip; however, there was no severe neurological finding warranting inpatient admission.  Additionally, there is no evidence of traumatic injuries.  The patient did have evidence of a left rib fracture.  There was no further documentation supporting an inpatient admission.  The documentation does not indicate why the patient cannot continue care at the observation level while in the ED.  Therefore, the prior denial remains upheld.
The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the hospital admission is not substantiated.  The insurer's denial is upheld.