Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left parietal subdural hematoma
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is upheld

This is the case of a patient with a history of hypertension (HTN) who presented to the emergency department (ED) with a nose laceration, headache, and knee pain obtained during an assault the day prior. As per the ED triage note the patient presented having been assaulted. He was alert and oriented in no acute distress (NAD). As per the provider note the patient presented to the ED with concern for being assaulted yesterday and having injuries to his left side of his face and left thumb. He denied nausea, vomiting, or syncope. He did have a headache. The exam revealed the patient to be well appearing in no apparent distress. There was an abrasion/contusion to the left side of his face. His pupils were equal round and reactive to light. A trauma consult was called who noted the history of being assaulted the day prior. Trauma surgery noted the patient denied LOC (loss of consciousness) and had only reported headache and some neck pain.  His GCS (Glasgow Coma Scale) was 15. They suggested getting a neurosurgical consult and an OMFS (Oral and Maxillofacial Surgery) consult. They noted that the computed tomography (CT) of the head showed left scalp swelling with acute appearing left parietal subdural hematoma which extended to the left tentorium. Maximum thickness was 5mm (millimeters). As per the trauma assessment flow sheet the GCS was 15 and the vital signs were stable with a blood pressure (BP) of 150/99 and the HR (heart rate) was 85.

As per the MCG (Milliman Care Guidelines) Health Inpatient and surgical care 26th Edition: Traumatic brain injury, non-surgical treatment. ORG: M-78 (ISC) an admission is indicated for 1 or more of the following: hemodynamic instability; altered mental status that is severe or persistent; Post resuscitation or a 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. MCG also noted that the Goal Length of Stay: 2 days. However, they also noted that "most patients with mild traumatic brain injury (Glasgow coma scale score 13 to 15) can be discharged from the emergency department after 4 to 6 hours of observation (e.g., normal examination, negative head CT if indicated), except in the case of anticoagulation or intoxication for which a longer period of observation (12 to 24 hours) may be needed." 

The reviewer agrees with the insurer that the full inpatient admission was not medically necessary but rather the patient could have been placed on an observation status. Thus, the denial is upheld. There was no indication of need for inpatient admission as noted by MCG guidelines. Finally, the reviewer is knowledgeable in this condition and the recommended health care services provided for this condition. The reviewer does believe that based upon these findings the health care plan did act reasonably and with sound medical judgment. The criteria the reviewer has utilized included my own personal experience as to what constitutes good acceptable standard of care and MCG care guidelines. The denial is therefore upheld. 

The insurer's denial of coverage for a full hospital admission is upheld. Medical Necessity is not substantiated.