Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bilateral mandibular fractures.
Treatment: hospital admission.
The insurer is denied coverage for hospital admission.
The denial is upheld. 

This male patient has a history of heterozygous hemoglobinopathy AC trait.

Milliman Care Guidelines (MCG) Health noted in General recovery care 25th edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: Hemodynamic instability; Hypertension requiring inpatient  treatment; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern; Severe heart failure; Severe respiratory findings; Severe airflow or ventilation abnormalities; Impending or actual respiratory arrest; Neurologic abnormalities; New-onset severe neurologic findings; Suspected acute intra-abdominal process; Severe physiologic disorder; Abdominal abnormalities; Acute renal failure; Significant uremic complications; High fever or other high-risk infection situation: Temperature less than 95 degrees Fahrenheit (35 degrees Celsius) (rectal); Severe electrolyte abnormalities requiring inpatient care; Acute blood loss causing significant abnormality; Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; Severe adverse drug or systemic toxin reaction requiring inpatient treatment; Severe pain requiring acute inpatient management: Severe malnutrition as indicated by 1 or more of the following: Estimated nutritional intake of less than 25% of calculated energy needs, Body mass index of less than 18.5, Body mass index of less than 20 and unintentional weight loss of 5% or more of usual body weight; Severe behavioral health issues; Inpatient monitoring  needed; Treatment requiring inpatient care; Emergency procedures needed. Based upon these guidelines this patient could have been observed rather than an acute admission as he did not have any indication as noted above for inpatient stay.
Furthermore, According to MCG Health Guidelines General recovery care 25th Edition: Head and neck surgery or procedure GRG ORG: SG-HNS (ISC GRG) the operative Status Criteria is Ambulatory: Most eye, middle ear, inner ear, or nose surgeries; Some pharyngeal airway procedures for sleep apnea; Most biopsy procedures; Most simple drainage procedures without drain in place; Most major dental procedures; Operations for hearing loss; Cleft palate or lip operations; Most vocal cord operations; Many cyst or sinus remnant operations; Epistaxis control with ALL of the following: No posterior packing, No procedures endangering airway; Tonsillectomy or adenoidectomy (or both) without complication (e.g., hemorrhage). This patient had ORIF(Open reduction and internal fixation) of bilateral mandibular fractures which would be considered as a major dental procedure and should have been in performed in an observation status and not as an inpatient admission.
Finally, in terms of what the hospital stated that the patient met the guidelines for MCG Health Guidelines General recovery care 25th Edition: Multiple trauma GRG: PG-MTR (ISC GRG), they are in error. This patient did not have multiple trauma and these guidelines are not appropriate for this case. This patient did not meet any of the criteria as he only needed observation as he did not have a significant injury requiring inpatient status.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

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