Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma  
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission.
The denial is upheld.

This is the case of a male with past medical history (PMHX) of hypertension (HTN), diabetes (DM), and coronary artery disease (CAD). As per the emergency department (ED) provider note, the patient reportedly was running from someone and fell backwards on the sidewalk, striking his head. Per bystanders, he had loss of consciousness (LOC). Emergency medical services (EMS) stated that on their arrival the patient was awake with Glasgow Coma Scale (GCS) 14, confused to date. The patient currently reported pain to the back of his head and neck but denied any chest or abdominal pain. On exam, he was well appearing, in no apparent distress. He had full range of motion to all extremities. His vital signs were stable. Labs were remarkable for slightly elevated blood glucose. Hematocrit was 44.5. The initial recommendations were cervical spine scan, labs, intravenous (IV) fluid. Computed tomography (CT) cervical spine was negative for acute cervical spine compression or fracture. CT of the head was negative for acute intraparenchymal hemorrhage. CT of the abdomen /pelvis was negative for solid organ abdominal injury. CT of the chest was negative for acute injury.  

MCG (Milliman Care Guidelines) Health General recovery care 25th edition General admission criteria noted that admission is indicated for 1 or more of the following: hemodynamic instability, hypertension requiring inpatient treatment, acute cardiac or peripheral ischemia, cardiac arrhythmias of immediate concern, severe heart failure, severe respiratory findings, severe airflow or ventilation abnormalities, impending or actual respiratory arrest, neurologic abnormalities, new-onset severe neurologic findings, suspected acute intra-abdominal process, severe physiologic disorder, abdominal abnormalities, acute renal failure, significant uremic complications, high fever or other high-risk infection situation, temperature less than 95 degrees Fahrenheit or 35 degrees Celsius (rectal), severe electrolyte abnormalities requiring inpatient care, acute blood loss causing significant abnormality, severe anemia, high-risk low platelet count, disseminated intravascular coagulation, severe adverse drug or systemic toxin reaction requiring inpatient treatment, severe pain requiring acute inpatient management, severe behavioral health issues, inpatient monitoring  needed, treatment requiring inpatient care, emergency procedures needed, or severe malnutrition as indicated by 1 or more of the following: estimated nutritional intake of less than 25% (percent) of calculated energy needs, body mass index of less than 18.5, body mass index of less than 20 and unintentional weight loss of 5% or more of usual body weight. 

Based upon these guidelines, this patient could have been observed rather than an acute admission as he did not have any indication as noted above for inpatient stay. His GCS score was initially 14 and eventually 15 and therefore did not have any indication for acute full hospital admission. This patient had a GCS of 14 to 15, did not have severe nausea or vomiting or worsening of neurologic function, and therefore only required observation and not a full inpatient admission. 

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

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