Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) Vehicle Collision
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female teen with medical history significant for depression status post suicide attempt by ingestion, oppositional defiant disorder, and patellar tendinitis of the left knee, non-compliant with medications. She walked in to the ED (emergency department) after being struck on the left side by a moving vehicle. She had run away from home three days prior. She had no vomiting or loss of consciousness. She took ibuprofen from a nearby store with some relief but was concerned by the bump on her head that seemed to be increasing in size. She also observed tensing of the muscles on the right side of her body that resolved after Tylenol.

The patient's vital signs included temperature 36.9, heart rate 77, respiratory rate 16, and blood pressure 127/76. Full trauma x-rays and CTs (computed tomographies) were obtained in the ED (emergency department), with possible acute nondisplaced fracture at the epiphysis of the right fibular head, mild soft tissue swelling in the right frontal scalp location representing scalp contusion with no evidence of intracranial bleeding, small right apical pneumothorax, and post-traumatic pseudocyst of the right lower lung lobe with adjacent pulmonary contusion. HIV (human immunodeficiency virus), RPR (rapid plasma regain), and hepatitis B surface antigen were sent.

Trauma Surgery and Orthopedic Surgery were consulted. The patient was provided with constant 1 to 1 observation due to suicidal ideation. She was stable in room air, admitted for further evaluation, pain management as needed, psychiatric evaluation and treatment, and social clearance. Admission orders included continuous pulse oximetry, regular diet, 1 to 1 monitoring, incentive spirometry, analgesia with Tylenol and Motrin as needed, Inpatient Psychiatry follow-up, Bacitracin for abrasions, and social clearance. Orthopedic recommendations included ice and elevation, weight bearing as tolerated, pain control, and clinic follow-up. Home psychiatric medications were resumed, including Prozac, Risperdal, and Seroquel.

The patient complained of headache overnight as well as shoulder pain, medicated with Motrin. The following day, she was able to ambulate with only slight pain. Her oral intake was at baseline, and she expressed no suicidal ideations. The full psychiatric consultation was completed that day. Recommendations included baseline lab studies and electrocardiogram, continuation of Risperdal and Prozac, discontinuation of Seroquel, and ongoing 1 to 1 monitoring. Trauma had no interventions to recommend. Social Services also consulted that day with plans to communicate with the mother when she was off work. Per Psychiatry follow-up, she remained a potential danger to herself and strong recommendations were made not to discharge until outpatient follow-up was securely in place. She remained compliant with staff, medications, and interventions. The mother was initially hesitant to take her home because of her history of erratic and violent outbursts and running away, but outpatient referrals were put into place, and the patient was cleared for safe discharge.

Yes, the full duration of the hospitalization was medically necessary and appropriate.
This patient was initially admitted as a trauma patient, having sustained injuries in an auto versus pedestrian accident (pulmonary contusion, fibular fracture, soft tissue scalp hematoma). However, it became readily apparent that she had a very complex psychiatric history with violent and unpredictable behavior outbursts, a potential suicide attempt, medication non-compliance, frequent episodes of running away, and frequent ED (emergency department) visits. She required acute psychiatric care that could be provided for her during this admission concurrent with her medical care, allow for stabilization, with establishment of an appropriate plan for ongoing outpatient care. To send her home prior to having plans for safe discharge in place, particularly with repeated documentation from the Psychiatry service that she was a potential risk to herself and unsafe to discharge, would have been irresponsible and dangerous. To accomplish safe discharge, she needed to resume her home medications, demonstrate appropriate compliance and behavior, her mother had to be actively involved in the discharge plan, and outpatient follow-up had to be established and in place. Social Services was daily querying the appropriate outpatient referral services to establish follow-up. Once all was accomplished and in place, she was safely discharged home.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.