Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a male with a past medical history significant for chronic alcoholism who presented to the hospital due to falling downstairs while being intoxicated. Reportedly, he was drinking with his friends the night before his presentation and became intoxicated. He decided to go home, and while walking, fell down a flight of stairs landing on his left side. He then took a bus home. Reportedly he started to experience significant pain, and this prompted his wife to activate Emergency Medical Services (EMS). The pain was on the left side of his thorax and face.

The subject under review is the medical necessity for the inpatient stay. 

The initial evaluation in the emergency department revealed acute left posterior lateral 6th through 9th rib fractures. There was also left medial orbital wall fracture, left zygomatic arch fracture, left orbital soft tissue swelling.Computed tomography (CT) scan of the head demonstrated no acute intracranial bleed or depressed skull fracture. It showed acute depressed medial left orbital wall fracture with blood and fluid in the left ethmoid sinus. There was acute partially visualized left zygomatic arch fracture. CT scan of the chest demonstrated acute left posterior lateral 6th-9th rib fractures with minimal underlying left lower pleural effusion and pleural thickening. There was no open pneumothorax.

The patient was admitted to the hospital with multiple rib fractures on the left side, fracture of the zygomatic arch, fracture of medial wall of the left orbit, and alcohol abuse.

During the hospital stay the patient was seen by an ophthalmologist who repaired the laceration of the left upper lid, and recommended treatment with Augmentin for 10 days. It was also recommended to apply ice to the affected area as well as follow-up in the ophthalmology clinic.
In the hospital the patient was also seen by dental service who also recommended treatment with Augmentin, ibuprofen for pain control, maintaining nasal precautions, and following up as an outpatient. During the hospital stay the patient did not develop any alcohol withdrawal symptoms.

He was discharged from the hospital in stable clinical condition.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

The inpatient stay was not medically necessary for this patient. 
This patient presented to the hospital following a fall that resulted in multiple rib fractures as well as zygomatic arch and the medial wall of the left orbit fractures. Although the rib fractures could lead to potentially dangerous complications, in this clinical case the patient remained in stable clinical condition. The patient remained hemodynamically stable, had no evidence of flail chest or acute respiratory failure. The patient did not require pain control provided in inpatient settings. His rib fractures were not associated with infection, hypoxemia. The patient did not need immediate inpatient surgery.
The patient also did not require any surgical intervention or inpatient pain control for the zygomatic arch and medial orbital wall fractures.
It was documented that the patient was recommended treatment with oral antibiotics and oral medications for pain control.
Overall, he remained in stable clinical condition and did not require any diagnostic studies, procedures, or treatment necessitating admission at the acute inpatient level of care. 
The patient could have been managed at a lower level of care status.