Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Syncope And Left Zygomatic Fracture.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned.

The patient is a male. He has PMH (past medical history) of gunshot wound, stab
injury, bipolar disorder, and polysubstance abuse.  He was transferred from another
hospital for left comminuted zygomatic bone fracture for further evaluation.  The
patient noted that after he woke up in the morning he smoked and then felt
nauseous and lightheaded and then lost consciousness, hitting his left side of the
head on the concrete floor.  The patient reported pain on the left side of the face
otherwise denied any symptoms.  The staff of the transferring hospital noted that
when they found him on the floor, he had no seizure activity or urinary incontinence.  
The patient also denied the use of cocaine for the last eight months.  He did have a
history of syncope in the past.

The patient's vitals and physical exam were unremarkable, except for subconjunctival hemorrhage in the left eye.  The left zygomatic arch was tender on palpation along with surrounding edema, scab and ecchymosis.  Also, multiple missing teeth were noted.  Otherwise, the head and neck exams were unremarkable. CT (computerized tomography) scan confirmed left Zygomatic bone and lateral orbital wall fracture; otherwise, workups were normal.  Also, urine toxicology was negative for cocaine. 

The patient was admitted for further evaluation of syncope, and the surgical intervention of zygomatic fracture as per Oro-maxillofacial surgery (OMFS) recommendation.  He was evaluated by a psychiatrist, ID (infectious disease), and Ophthalmology.  Pain control, IV (intravenous) antibiotic, close monitoring was continued.  The patient underwent Holter monitoring, echocardiogram and EEG (electroencephalogram).  The results were negative.  Eventually, he was cleared by cardiology for the procedure.

Ultimately, the patient underwent surgical intervention (ORIF [open reduction
internal fixation]) for left zygomatic bone fracture.  The patient was later cleared by
OMFS and was discharged with PO (oral) Augmentin and pain medications with advice to see a Primary Care physician and OMFS in seven days.

Yes, the Inpatient admission was medically necessary.

This male was initially evaluated in a different hospital for syncope.  He was found
to have a left facial injury and loss of multiple teeth.  CT showed left zygomatic bone and left orbital wall fracture.  Subsequently, he was transferred to the current hospital for OMFS evaluation and management of his facial injury/fracture.  As per oro-maxillofacial surgery recommendation, he was started on IV antibiotics and pain management while he was waiting for surgical clearance.  This patient had a previous history of syncope.  Even though he was a cocaine abuser, this time his toxicology screen was negative.  The patient underwent a workup for possible etiology of syncope prior to the procedure, while medical management was continued.  The patient eventually underwent ORIF once cleared by cardiology.  As per the journal 'The Laryngoscope,' traumatic facial injury presents a significant burden and is associated with high comorbidity and mortality.  It also noted management of facial trauma often results in surgical intervention.  The use of perioperative antibiotics in patient management is the current recommendation and is often combined with pre-or-postoperative antibiotics to reduce infection complications.  In this specific clinical scenario, inpatient admission was standard of care and medically necessary.