Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	Syncope/Trauma	

Treatment:  Inpatient Admission

The insurer denied inpatient admission.  The denial is upheld. 

According to the triage note at 20:03, the patient fell down a flight of stairs. The nurse noted the patient did not want to disclose how much he drinks. The patient self-discontinued his cervical collar. He denied pain, dizziness, or tremor. ETOH (alcohol) level was elevated. He was able to walk to the bathroom with steady gait. His breathing was unlabored. He did have left shoulder gross ecchymosis. Glascow coma scale (GCS) score was 15. Vital signs were stable.

The emergency department (ED) provider notes indicated the patient was found unresponsive at the bottom of the steps. He did not remember what happened, and the patient admitted to drinking. Exam revealed bruising to the left shoulder. The Trauma Service was to see the patient.

Primary survey revealed left shoulder ecchymosis with a small open pinpoint wound to the left shoulder area and no other external injuries noted. His exam was unremarkable except for the shoulder ecchymosis. The recommendation was admit to trauma surgery.

Physical therapy (PT) saw the patient the next day. His disposition was PT at home. Progress notes by trauma at 11:58 indicated the X rays were reviewed, and there was no fracture noted.  This included CT (computed tomography) scan of the head, C (cervical) spine, and CT of the abdomen. CT of the chest revealed left shoulder soft tissue swelling / hematoma with 2 foci of contrast extravasation. The subclavian artery was intact. The plan was to discharge to home that day.

Based upon the information provided, the hospital inpatient admission is not approved at the acute inpatient level, as the patient could have been treated on an observation status without an acute inpatient admission.  The patient did not meet criteria based upon Milliman Care Guidelines (MCG) guidelines. As per MCG Health Guidelines Inpatient and Surgical Care 27th Edition: Traumatic brain injury, nonsurgical treatment ORG: M-78 (ISC) admission is indicated for 1 or more of the following: hemodynamic instability; altered mental status that is severe or persistent; Post resuscitation or presenting Glasgow coma scale score of less than 13; Worsening of neurologic function post presentation (e.g., declining mental status, deteriorating Glasgow coma scale score); New signs or symptoms (e.g., dizziness, vomiting, headache) that are severe, or persist despite observation care; New focal signs on neurologic examination; Evidence of increased intracranial pressure (ICP) (e.g., papilledema, Bradycardia); New (or presumed new) intracranial pathology on imaging (e.g., CT scan) that requires intervention or monitoring beyond the observation care time frame; CSF (cerebrospinal fluid) leak; Recurrent seizures; Significant respiratory (e.g., neurogenic pulmonary edema) or cardiac (e.g., arrhythmia) abnormalities secondary to brain injury; Increased intracranial pressure or cerebral edema monitoring.  This patient did not require acute inpatient admission care; his GCS was 15; he needed only to be observed; he was discharged the following day. Thus, admission was not warranted at the acute inpatient level but rather as an observation status. 

Furthermore, as per MCG Health Guidelines MCG Health Guidelines General recovery care 27th Edition: musculoskeletal disease GRG: MG-MD (ISC GRG)  hospital admission is needed for appropriate care of the patient because of 1 or more of the following: Bone, joint, muscle, or orthopedic device infection (e.g., periprosthetic infection that requires inpatient care; Vertebral fracture that requires inpatient care (MEDICAL); Nonvertebral fracture, dislocation, or other musculoskeletal injury that requires inpatient care as indicated by Compartment syndrome (proven or cannot be ruled out during observation care), Major injury requiring inpatient care (nature of injury necessitates inpatient treatment or monitoring), severe pain requiring acute inpatient management; Rheumatologic disease (e.g., systemic lupus erythematosus, rheumatoid arthritis, spondylarthritis) exacerbation or related finding that requires inpatient care; Vasculitis with complications or findings that requires inpatient care; Severe crystal arthropathy (e.g., gout, pseudogout) that requires inpatient care; Rhabdomyolysis that requires inpatient care; Myopathy that requires inpatient care; Postamputation complication that requires inpatient care; severe pain requiring acute inpatient management due to musculoskeletal condition. This patient did not require inpatient admission based upon these criteria. He did not need inpatient hospitalization, as there was no fracture noted - only soft tissue injury, which only needed to be observed.

In addition, MCG Health Inpatient and surgical care 27th Edition: Syncope ORG: M-340 (ISC GRG) also notes that admission is indicated for 1 or more of the following: hemodynamic instability; altered mental status that is severe or persistent; Cardiac disease or finding (e.g., results of echocardiogram or cardiac monitoring performed in observation care) that indicates necessity of immediate (i.e., not as a scheduled elective procedure) intervention (e.g., AICD [automatic implantable cardioverter defibrillator] placement, electrophysiologic study, surgery, prolonged telemetry monitoring); Pacemaker or AICD malfunction; Inheritable cardiovascular condition predisposing to arrhythmias diagnosed or suspected (e.g., Brugada syndrome, short QT syndrome, long QT syndrome);  dehydration that is severe or persistent; Syncope causing injury requiring hospitalization. Thus, there was no indication based upon syncope for inpatient care.

Finally with regards to what the hospital is raising with MCG Health Inpatient and surgical care 27th Edition: Hemodynamic instability: common complications and conditions CCC:CCC-019 (ISC) the indications for ongoing inpatient care is indicated for 1 or more of the following: Hypotension that is new or symptomatic; Symptomatic Tachycardia or Bradycardia unresponsive to treatment (e.g., analgesia, fluids); Inadequate perfusion as indicated by 1 or more of the following: Lactate of 2.0 mmol/L (18 mg/dL) or more secondary to hypotension (i.e., hypoperfusion), Metabolic acidosis (arterial or venous pH [power of hydrogen] less than 7.35) not otherwise explained, Orthostatic vital sign changes that are symptomatic and unresponsive to treatment (e.g., fluids);IV inotropic medication or vasopressor medication required.  In this case there was no indication for inpatient care using these guidelines.

The reviewer, therefore, agrees with the insurer, that the inpatient admission was not medically necessary at the acute inpatient level, as the patient should have been placed on an observation status. Thus, the denial is upheld. There was no need for inpatient admission as noted by MCG guidelines as the care could have been given in an observation status. 

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 full hospital admission services were not substantiated.