Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Puncture would of chest, back, abdomen, right upper extremity and left lower extremity. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

According to the documentation submitted, this is an adult male who was admitted to the hospital for knife stab wounds to the chest, back, abdomen, right upper extremity and left lower extremity. The patient was admitted to the Trauma service, and he underwent laceration repair. Once the patient was deemed medically stable, he was discharged on with instructions for outpatient follow up. 

Per Milliman Care Guidelines (MCG) Health Guidelines General Recovery Care 25th Edition: Multiple Trauma): Hospital admission is indicated when a patient with significant multiple trauma requires inpatient care for 1 or more of the following: Major surgical and postprocedural care; Nonoperative care of significant injury; multiple trauma and one or more general admission criteria. MCG notes that alternatives to admission include: Outpatient care in emergency department (ED), rapid treatment site, or urgent care center, X-rays and wound care as indicated, Surgical evaluation, Diagnostic testing (e.g., CT (computed tomography) scan, ultrasound), Observation of patient without urgent surgical requirements, Repeat testing (e.g., hematocrit, ultrasound); Home care: Wound care, Facilitation of specialty follow-up, Physical therapy. 

As per the ED provider note, the patient had no significant past medical history and presented with multiple stab wounds to the right hand, abdomen and back. He denied any chest pain or shortness of breath. He did admit to drinking alcohol and smoking marijuana. On exam, his vital signs were stable; he was normotensive and he had a Glasgow Coma Scale (GCS) score of 15. He had normal breath sounds, and his abdomen was soft and non-distended. There was no abdominal tenderness. The patient had normal range of motion to his extremities. The plan was for CT of abdomen, chest, and pelvis, IV (intravenous) fluids, and Ancef. His hemoglobin was 13.1 and white blood cell (WBC) count was 4.8. Chest X-ray and fast scan were negative. The patient's vital signs included a blood pressure of 117/72, heart rate of 60 and respiratory rate of 18. 

The CT of the abdomen showed multiple superficial stab wounds within the bilateral chest wall/ abdominal wall. None of these wounds showed deep penetration with any violation of the pleura or retroperitoneum. There was a small amount of extravasation within the abdominal wall defect on the left. There was no clear arterial defect visualized with minimal expansion on delayed sequence, suggestive of intramuscular bleed. Surgery noted the patient was admitted to trauma surgery for observation. 

The Trauma chief resident in surgery saw the patient and noted the stab wounds to the right inferior axilla on the chest wall, stab wounds to mid posterior thorax, right hand laceration, right inferior flank stab wounds and right posterior upper arm stab wounds. He noted the upper arm wounds were not in proximity to vessels and without neurovascular deficits. The patient had multiple stab wound lacerations repaired including right upper extremity, right axillary, right hand at base of thumb, left lower quadrant at the midaxillary line, and posterior thorax at the mid thoracic level x (times) 2. There was no tendon involvement. 

This patient did not have the indications for admission based upon the above criteria. Therefore, the inpatient admission was not medically necessary at the acute inpatient level but rather the patient could have been placed on an observation status as even the progress note noted that the patient was admitted for observation. 

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient is not substantiated.