Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest wall pain

Treatment is an inpatient admission 	

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

This patient with a PMHX (primary medical history) of hyperlipidemia and colon resection presented to the ED (emergency department) with complaints of chest wall pain. The patient presented to the triage nurse with stable vital signs and mid thoracic pain. He reported tripping and falling down 3 steps of stairs and falling on his back. He denied SOB (shortness of breath). He was seen by the ED provider who noted the history of back pain after falling yesterday. He was walking into his home when he slipped on the ice on his deck outside of his home and landed onto his left posterior lateral ribs. He noted a sharp aching sensation worse upon motion. In exam he was afebrile with chest wall tenderness on the left side. A CT (computed tomography) of the chest revealed acute mildly displaced fractures involving the posterior lateral aspects of the left fifth, sixth ribs as well as acute nondisplaced subtle buckle fractures of the anterior left fourth, fifth and sixth ribs. There was no pleural effusion noted. Trauma surgery was consulted. The treatment plan noted that the patient appeared well with no obvious evidence of traumatic pathology. The patient was offered analgesia but refused at this time.
Trauma surgery saw the patient and noted the history. The plan was to admit to trauma for multiple rib fractures. WBC (white blood cell count) was 9.1. Hct (hematocrit) was 45.

MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care 26th Edition: Rib fracture: observation care ORG: OC-0-59 (ISC) notes that observation care is indicated for 1 or more of the following: Pain persistent despite emergency department care; Dyspnea or tachypnea; vital sign abnormality; Inability to cough or breathe deeply (e.g., due to pain); Traumatic rib fractures with suspected associated intra-abdominal, vascular, brachial plexus, or other significant injury (e.g., pneumothorax); Patient with underlying risk factors for complications (e.g., elderly patient, patient with symptomatic cardiopulmonary disease); Displaced rib fracture or fractures. Thus, in this case all that the patient required was observation care.

I, therefore, agree with the insurer that the inpatient admission was not medically necessary at the full hospital admission but could have been placed on an observation status. Thus, the denial is upheld. There was no indication of need for inpatient admission as noted by MCG guidelines. Finally, I am knowledgeable in this condition and the recommended health care services provided for this condition. I do believe that based upon these findings the health care plan did act reasonably and with sound medical judgment. The criteria I have utilized included my own personal experience as to what constitutes good acceptable standard of care and MCG care guidelines. The denial is therefore upheld. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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