Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skull fracture
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

According to the emergency department (ED) provider note, this is a child who was brought to the ED by their mother following a fall from a standing height onto wood floors 2-3 hours prior to admission. The patient cried immediately and then calmed down. There was no emesis or seizure like activity or mental status change. The patient had been acting normally. No past medical history (PMHX) was noted.  The patient was afebrile with stable vital signs. There was tenderness to the right parietal region over a parietal hematoma. There was no skull depression or other anomaly noted. The patient was alert and actively playful, moving all extremities. The assessment was fall with parietal hematoma. The plan was observation due to size of injury and tenderness. The plan was to geta computed tomography (CT) of the head. The CT of the head showed a minimally displaced skull fracture appreciated and question of a small epidural hematoma. Neurosurgery was paged.

Based upon the information provided, the inpatient hospital admission was denied 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). As per MCG Health Guidelines Inpatient and Surgical Care 27th Edition: Traumatic brain injury, Nonsurgical treatment, Pediatric admission is indicated for 1 or more of the following: hemodynamic instability, post resuscitation or presenting Glasgow coma scale score of less than 13, worsening of neurologic function post presentation (e.g. ["for example"], declining mental status, deteriorating Glasgow coma scale score), new focal signs on neurologic examination, new signs or symptoms (e.g., dizziness, vomiting, headache) that are severe, or persist despite observation care, altered mental status that is severe or persistent, evidence of increased intracranial pressure (ICP) (e.g., papilledema, bradycardia, full fontanel, split sutures), new (or presumed new) intracranial pathology on imaging (e.g., CT scan) that requires intervention or monitoring beyond the observation care time frame, cerebrospinal fluid (CSF) 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. Alternatives include: outpatient care in ED, rapid treatment site, urgent care clinic, or medical office, hourly neurologic assessment for 4 to 12 hours, discharge to home for careful observation if no indications for admission present, and if responsible adult available to monitor for clinical deterioration. The goal length of stay is 1 day. In this case the patient did not require admission care as they did not have findings that warranted an admission but rather as was noted in the progress notes monitoring. The patient did not have vomiting following their injury and did not have a subarachnoid hemorrhage or any neurologic finding. Thus, admission was not warranted but rather observation. 

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 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, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.