Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall in Home

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is upheld.

This is the case of a patient with a past medical history of hypertension, diabetes, and asthma who presented to the emergency room (ER) with complaints of back and neck pain after falling. The patient presented with blood pressure (BP) of 160/100 and heart rate (HR) of 106 and respiratory rate (RR) of 20. As per the emergency department (ED) provider note, the patient complained of a fall from standing with injury to the head. There was no loss of consciousness (LOC). On exam, she had a deep laceration to the lip. The patient was alert and oriented, with spine appearing to be normal and range of motion not limited. There were no focal neurologic findings. The plan was to admit to medicine. Trauma level 2 was activated. A 2 cm (centimeter) laceration to the upper lip was noted. The patient had a C (cervical) collar on. Labs showed a WBC (white blood cells) of 12.5 and a HCT (hematocrit) of 40.3. C spine did not show any acute osseous injury. Computed tomography (CT) of the head showed no acute intracranial process. Chest x-ray (CXR) showed mild pulmonary congestion with no evidence of focal pneumonia. Pelvic x-ray showed no acute fracture of dislocation. The trauma recommendation noted that there no were no acute traumatic injuries identified. However, patient had persistent C spine tenderness - unable to clear C collar. The decision was to admit to trauma service for pain management. The laceration of the lip was repaired by plastic surgery with follow up as outpatient for suture removal.

Based upon the information provided, the inpatient hospital stay is denied as the patient could have been treated on an observation status without an acute inpatient admission as this procedure - laceration repair of the upper lip did not require an inpatient admission. Furthermore, she did not have LOC from her fall. She did not have any focal findings and the x rays did not reveal any acute process. Pain management could have been done in an observation status. The patient did not meet criteria based upon Milliman Care Guidelines (MCG) as noted by the insurer, as there were no associated risk factors that would have necessitated inpatient surgery. 

According to MCG Health Guidelines General Recovery Musculoskeletal surgery or procedure, the Operative Status Criteria is ambulatory for procedures such as: closed or open reduction of simple fractures, simple internal fixations, simple external fixations, simple wound repairs, plastic operations on tendon or joints, bone biopsies, removal of most orthopedic devices. Thus, using these guidelines, the patient did not require inpatient admission but rather a 23 hour observation. The patient could have been managed within 23 hours and, as can be seen, did not require inpatient admission. She did require care, but this could have been done with a 23 hour observation status and not an acute inpatient admission.

The inpatient hospital stay was not medically necessary at the acute inpatient level, but rather the patient could have been placed on an observation status. The health care plan did act reasonably and with sound medical judgment. 

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