Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skull fracture. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

According to the History and Physical the patient was transferred after trip and fall over a robotic vacuum and was admitted to the Pediatric Intensive Care Unit (PICU). She cried immediately but had no loss of consciousness (LOC) or bleeding. After a couple of hours, she began to have multiple non bloody non bilious emesis which persisted throughout the night prompting her mother to take her to the Emergency Department (ED) in the morning. She was found to have a subarachnoid hemorrhage (SAH) and non-displaced occipital skull fracture and was therefore transferred for evaluation and monitoring. On exam, she had stable vital signs. Her computed tomography (CT) of the brain in the ED showed scattered areas of right hemispheric subarachnoid hemorrhage and non-displaced occipital bone fracture and right scalp hematoma. Cervical spine x ray was normal. Her neurological (neuro) exam was normal. She was placed on every (q) 1 hour neuro checks, head of bed (HOB) up to 30 degrees, nothing by mouth (NPO) and intravenous (IV) fluid as well as Keppra IV. The patient was admitted. 

Pediatric trauma service saw the patient and agreed with the history and findings as well as plan. It was noted that neurosurgery saw the patient and recommended magnetic resonance imaging (MRI) of the brain given pattern of SAH involving the sylvan fissure. The patient was to be kept euvolemic and normotensive. 

Progress notes indicated the patient was stable. She was fed orally in the morning after no further episodes of emesis and reassuring MRI. 

Neurosurgery saw the patient and noted no clear evidence on MRI of the brain of underlying pathology, suggesting subarachnoid hemorrhage lining the sylvan fissure is traumatic in origin. The patient was cleared for discharge. 

The patient was discharged on Keppra. As per the discharge summary the patient was stable for discharge with the findings of MRI brain with small focal contusion in the right presylvan region with prominent right parietal scalp laceration with edema and subgaleal hematoma with partially reabsorbed subarachnoid hemorrhage. 

The patient met criteria for inpatient care based upon the physician judgment for the severity of signs and symptoms and predictability of something adverse happening to the patient as well as Milliman Care Guidelines (MCG) as she needed inpatient monitoring of vital signs, neurologic sign checks , initiation of Keppra and treatment for nausea and vomiting as well as pain management. 

This patient required admission and monitoring in the PICU. The patient did meet criteria based upon MCG guidelines. As per MCG Health Guidelines Inpatient and Surgical Care 27th Edition: Traumatic brain injury, Nonsurgical treatment, Pediatric ORG: P-202 (ISC). 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.