Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Fractures in Face s/p (status post) Fall
Treatment: Inpatient admission
The health plan denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male who presented to the hospital following a slip and fall accident. The patient complained of left facial pain and swelling. At the time of presentation his Glasgow Coma Score was 15, his heart rate was 85 beats per minute and his blood pressure was 199/95 millimeters of mercury (mmHg). There was facial and orbital swelling, ecchymosis and a laceration of the left. Imaging showed a left zygomatic arch fracture, a left maxillary sinus fracture, a left orbital floor fracture and a laceration to the left cheek. He was also found to have the Coronavirus (COVID) infection.
The patient was admitted to the hospital with COVID isolation precautions. In the course of this hospitalization the trauma service and oral and maxillofacial surgery (OMFS) services were consulted. The consulting OMFS services did not recommend any acute surgical intervention for the facial fractures due to the severity of the swelling. An outpatient follow up was recommended. The patient had a normal and stable neurological status. He had no visual disturbance. He was tolerating a diet and had normal vital signs. He was discharged from the hospital.

The denial letter from the health plan states that the tests and medicine could have been provided with a lower level of care, without full admission to the hospital. The letter references the Milliman Care Guidelines (MCG) 26th edition, for Musculoskeletal Disease and Multiple Trauma.

The submitted medical records do not support the medical necessity of an inpatient admission.

This patient presented to the emergency department (ED) following a fall from standing height in which he sustained facial lacerations and facial fractures. He was hemodynamically and neurologically stable at the time of his presentation to the ED. The evaluation and clinical work up identified a left zygomatic arch fracture, a left maxillary sinus fracture, a left orbital floor fracture and a laceration to the left cheek. He was also found to be COVID positive. The patient was stable at the time of presentation with normal vital signs. He was seen in consultation by the trauma service and OMFS service and it was determined that he did not require acute surgical intervention for the facial fractures. He was discharged from the hospital following these assessments with a planned ophthalmology and OMFS follow up.

The care and treatment provided could have safely been rendered without the need for an inpatient level of care. An alternate level of care would have allowed for the provision of intravenous (IV) fluids, pain medication, the necessary consultations and overnight monitoring. The records support that the patient had an uncomplicated period of observation. He remained hemodynamically and neurologically stable without aberration of vital signs. His Glasgow coma score was normal at 15 at the time of presentation. There was no hemodynamic instability and the patient was able to tolerate a diet. There is no documentation of severe pain requiring continuous or frequent (every 2 to 4 hours) parenteral analgesics. An alternate level of care would have satisfied the clinical needs of this patient.

According to the referenced MCG guidelines, an inpatient admission is indicated when a patient with significant multiple trauma requires inpatient care for 1 or more of the following: major surgical and postprocedural care, nonoperative care of significant injuries or other general admission criteria. In this case, none of these requirements were met for the patient and his care could have been provided at an alternate level of care.