Appeal type: Medical necessity
Decision: Upheld

Diagnosis: fractures of the 10th and 11th ribs.

Treatment: blunt thoracic admission protocol.

The insurer is denied coverage for full hospital admission.

The denial is upheld. 

This male patient has a history of epilepsy.

According to MCG Health Guidelines General recovery care 25th Edition: Rib fracture ORG: M-545 (ISC) Admission is indicated for 1 or more of the following: hemodynamic instability; Flail chest; Acute respiratory failure (e.g., mechanical ventilation needed or imminent); Pain (e.g., inhibiting ability to cough or clear airway) that requires inpatient treatment (e.g., not controllable in observation care, outpatient regimen cannot be established); Injury (e.g., intra-abdominal, vascular, neurologic, pneumothorax) identified that requires inpatient care; Rib fracture associated with infection that requires inpatient care (e.g., pneumonia too severe for outpatient treatment); tachypnea that persists despite observation care; Immediate inpatient surgery needed (e.g., for displaced rib fracture). 
In addition, MCG also notes that Extended care as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) may be needed for: Five or more fractured ribs and one can anticipate possible need for intensive care unit (ICU) care and mechanical ventilation and one can expect brief to moderate stay extension; Flail chest and anticipate noninvasive ventilation or continuous positive airway pressure (CPAP), possible intubation and mechanical ventilation, local or regional anesthesia, and possible surgical intervention and one can expect brief stay extension; Surgical intervention with surgical rib fixation may be considered for patient with flail chest, multiple severe displaced fractures, and failure of nonoperative management and one can expect brief stay extension; Respiratory insufficiency (e.g., due to pulmonary collapse, pneumonia, pleural effusion) and anticipate possible assisted ventilation and one can expect brief to moderate stay extension; Concomitant trauma to visceral or thoracic organs with increasing trauma score is associated with pulmonary complications, longer intensive care unit (ICU) stays, and more ventilator days and anticipate possible chest tube or other surgical intervention and one can expect brief to moderate stay extension; Need for chest tube drainage in patient with significant pneumothorax or pleural effusion may require chest tube drainage and one can expect brief stay extension; Significantly reduced forced expiratory volume in 1 (FEV1) second (e.g., FEV1 less than 1 liter) with reduced lung volumes may occur because of poor pain control and one can expect brief stay extension; Active comorbidities with exacerbation of comorbid illness [e.g., chronic obstructive pulmonary disease (COPD), congestive heart failure] may require longer hospital care  and one can expect brief stay extension, 
defined by unilateral fractures of at least 3 consecutive ribs, each fractured in 2 or more places, and is clinically characterized by paradoxical motion of the chest wall with breathing. The management include aggressive pulmonary toilet and pain management- both of which could have been done such that the patient only needed observation status.
There was no indication of need for inpatient admission as noted by MCG guidelines as the care could have been given in an observation status. Based upon these findings the health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.