Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a past medical history of substance abuse. He was evaluated in the ED (emergency department). The patient was struck on his left side by a moving vehicle while he was crossing the street. The patient fell, landing on his left side. There was no loss of consciousness.

In the ED (emergency department), the patient complained of left-sided chest and abdominal pain. His vital signs were normal. His mental status was normal. The physical examination documents tenderness to palpation over the anterior and lateral left chest extending to the upper abdomen. There were no other visible injuries. The patient underwent a comprehensive trauma evaluation in the ED (emergency department). CT (computed tomography) scans were performed from his head through his pelvis. The patient was found to have fractures of his left third through sixth the ribs. There was no pneumothorax or hemothorax. No other injuries were identified.

Following the patient's ED (emergency department) evaluation, he was admitted to the hospital. The admission note for this patient indicates that he would be treated with oral and topical pain medication. He would be allowed to have a regular diet. He would be evaluated by a pain management specialist. No other testing was anticipated for the patient. He would be encouraged to use an incentive spirometer frequently.

The following day, the patient's pain was well-controlled. He was tolerating an oral diet. He was ambulating independently. There was no respiratory difficulty. The patient was discharged home.

No the Inpatient admission was not medically necessary.
Following this patient's ED (emergency department) evaluation, he was clinically stable. The patient had normal vital signs. He had normal mental status. He had undergone a comprehensive trauma evaluation in the ED (emergency department). Extensive testing had revealed several rib fractures on the left side of his chest. No other injuries were identified. There was no evidence of pneumothorax or hemothorax. Despite these rib fractures, there was no respiratory distress.

The admission note for this patient indicates that he would be given oral and topical pain medication. The patient was not written for IV (intravenous) narcotic pain medication. He would be encouraged to use an incentive spirometer. He would continue taking methadone, which he had been taking before his hospital admission. The patient was written for a regular diet.

At the time that this patient was kept in the hospital, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a short stay in the hospital. For this reason, an observation stay would have been appropriate. There was no intensity of required services to justify an inpatient admission. The patient was not receiving IV (intravenous) narcotic pain medication. No additional testing or consultations were expected for the patient.

In conclusion, an inpatient admission was not medically necessary for this patient. He was clinically stable despite his rib fractures. A limited plan of care was anticipated for him. The patient could have safely and effectively been managed at a lower level of care.