Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head trauma.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

 
This is the case of a patient who was brought in by Emergency Medical Services (EMS) after striking another bicyclist; he was unhelmeted. Upon arrival to the emergency department (ED) his Glasgow Coma Scale (GCS) was 15. He was hemodynamically stable. Level 2 trauma activation was called. As per the ED provider note; the patient has an unknown past medical history and was on aspirin and Plavix. Per EMS, the patient was witnessed by bystanders striking his head and temporarily losing consciousness. He appeared mildly confused upon waking up. Upon EMS arrival, the patient had already returned to baseline mental status. The patient was noted to have sustained trauma to his nose and the back of his head. His vital signs were stable. Exam revealed GCS 15 and in no acute respiratory distress. There was a large occipital hematoma with bilateral epistaxis with no obvious septal hematoma and swelling to the bridge. There was a large left sided periorbital ecchymosis. There was no bony tenderness of the orbit. There was no midline cervical (C) spine tenderness to palpation. C collar was applied on arrival.  Neurologic exam showed 5/5 strength in bilateral upper and lower extremities. Sensation was grossly intact. C spine was negative. Computed tomography (CT) of the head and face showed possible intracerebral hemorrhage (ICH) versus mineralization. Radiology recommended short interval scan. There was bilateral nasal bone fractures as well as fracture of the left maxillary sinus and right orbital floor. The plan was facial consult, trauma consult, neurosurgery consult and repeat CT scan. 

The patient was admitted to trauma. The Focused Assessment with Sonography in Trauma (FAST) was negative. There was epistaxis from the right nare and left posterior scalp hematoma. The plan was CT of the spine, nothing by mouth (NPO), intravenous (IV) fluids, CT of the head.

A repeat CT was performed at reasonable interval and showed no evidence of acute intracranial injury. The facial bone fractures were seen as on prior scan.

Neurosurgery saw the patient and deemed no surgical intervention required. The patient was admitted to surgery for further monitoring. Progress note indicated that there was no need for further scans. The patient was cleared for physical therapy / occupational therapy (PT/OT) and no neurosurgical intervention was required.

Otolaryngologist saw the patient for the epistaxis and noted nasal packing placed. Hemostasis was achieved with absorbable packing which did need to be removed.

Neurosurgery saw the patient and noted the repeat CT in 6 hours. Neurosurgery also recommended holding anticoagulants until repeat scan.  Neurosurgery noted that repeat CT of the head demonstrated that these likely calcifications are in fact calcifications/mineralization, and therefore no role for neurosurgery.

Progress note by trauma indicated the patient had no complaints. Repeat CT scan showed no acute injury. Neurosurgery noted no further surgical intervention. The patient was admitted for further monitoring. During PT evaluation the patient became hypotensive and received 1 liter bolus. Currently the patient was stable. The plan was analgesia, diet and Augmentin for 7 days as well as PT.

The patient was discharged. At the time of discharge, the patient was tolerating a soft diet without nausea or vomiting.

He could have been treated as observation and was cleared by neurosurgery. 	

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the acute inpatient admission is not substantiated.