Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head Trauma
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a male patient with a history of anxiety. He presented to the Emergency Department (ED) with complaints of loss of consciousness after being in a physical assault. On physical examination he was noted to have a 5 cm posterior scalp hematoma without active bleeding and a 2 cm laceration to the left of the nose. Neurology consulted on the patient. He had a computed tomography (CT) imaging of the spine and brain; the spine was negative for acute fracture and the brain revealed a posterior right parietal occipital scalp hematoma with no acute intracranial hemorrhage noted. A comminuted bilateral nasal bone fracture was noted. Orbits and calvarium were intact. The patient complained of double vision; an ophthalmology consult was performed. It was determined that his symptoms were as a result of post concussive syndrome. 

Based upon the information provided, the hospital inpatient admission is not approved as the patient could have been managed in an observation status.  The patient was status post blunt trauma to head and face and did have temporary loss of consciousness. On exam radiologically, he was found to have no intracranial bleeding and a Glasgow Coma Scale score was 15. He did have temporary diplopia which resolved. He did have nasal bone fractures, but otherwise no other acute injury of note.  Surgery evaluated him and felt the patient needed to be observed. Thus, this patient did not need anything more than observation and not an acute inpatient admission. His care could have been managed on an observation status as the patient was stable and was discharged the following day.

According to MCG Health Traumatic Brain Injury, Nonsurgical Treatment: Observation Care Inpatient and Surgical Care 23rd Edition: ORG: OC-063 (ISC) observation may be appropriate for patient with head injury and 1 or more of the following: vital signs abnormality; altered mental status; Temporary loss of consciousness at time of injury; Suspicion for vascular injury (e.g., penetrating injury, soft tissue swelling of the anterior neck); Dizziness or vomiting beyond immediate postinjury period; Posttraumatic seizure; Presence of elevated intracranial pressure (ICP) or cerebral spinal fluid (CSF) leak suspected (monitoring needed beyond usual 3 to 4 hour time frame for emergency department care).

Furthermore, as per MCG Health Inpatient and Surgical Care 23rd Edition Traumatic Brain Injury, Non-surgical Treatment ORG: M-78 (ISC) Admission is indicated for head injury and 1 or more of the following: hemodynamic instability; altered mental status that is severe or persistent; Post resuscitation or presenting Glasgow coma scale score of less than 13; Worsening of neurologic function post presentation (e.g., declining mental status, deteriorating Glasgow coma scale score); New signs or symptoms (e.g., dizziness, vomiting, headache) that are severe, or persist despite observation care treatment...Finally as per MCG Health General Recovery care 23rd Edition Medical Admission Case Management Care: Head and Neck Disease GRG: MG-HND (ISC GRG) Hospital admission is needed for appropriate care of the patient because of 1 or more of the following: Diplopia associated with 1 or more of the following: Orbital or facial trauma; central nervous system [CNS] infection suspected; Vascular etiology suspected (e.g., compressive aneurysm, basilar artery thrombosis, vertebral dissection).  

In this case the patient had diplopia which resolved following a period of observation. Therefore, an inpatient admission was not warranted, but rather only observation.

The health care plan did act reasonably and with sound medical judgment and in the patient's best interest.  

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.