Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right nasal bone fracture and periorbital edema

Treatment inpatient stay

The insurer denied coverage for inpatient stay

The denial is upheld

This is the case of an adult male who presented to the hospital as a level 2 trauma activation after an assault. The patient's injuries included right nasal bone fracture and periorbital edema.  He was intubated. He was extubated as per progress note after all of the X-ray studies were done. Progress notes indicated the patient was very drowsy but does not report any pain in his eye. He did have pain in his face. His vital signs were stable. He was admitted to telemetry for further monitoring.

As per the trauma consultation he was severely agitated in the trauma bay. Primary survey indicated intact Glasgow Coma Scale (GCS) 15, alert and oriented to person, place and time. Secondary revealing showed periorbital edema of the bilateral eyes and lips swelling. The initial recommendation was intubation as he was severely agitated for imaging to be done. The plan was for pan scan maxillofacial computed tomography (CT). The plan was to extubate the patient depending on labs and scan findings. CT of the head revealed no acute traumatic injury except for nasal bone fractures and left periorbital swelling. CT of the spine revealed no acute traumatic injuries. CT chest revealed no acute traumatic injuries. CT of the abdomen and pelvis showed no acute traumatic injuries. Fast was performed and showed no evidence of pelvic fluid. The attending noted that in order to obtain the above imaging in this patient with altered mental status from ethanol alcohol (ETOH)/ other substance use, the patient was intubated and sedated. Now that the results show no intracerebral hemorrhage (ICH) or other injuries he will be weaned and extubated. The plan was for outpatient follow up with plastics and ophthalmology to evaluate periorbital swelling.

His pain was well controlled and throughout his hospital stay there were no acute events and his vital signs remained stable. He was deemed stable for discharge from a trauma perspective and was discharged to home.

Milliman Care Guidelines (MCG) Health noted in General Recovery Care 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 (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 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; Severe behavioral health issues; Inpatient monitoring  needed; Treatment requiring inpatient care; Emergency procedures needed. 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.

Based upon the information provided, the hospital inpatient admission is denied as the patient could have been treated on an observation status without an acute inpatient admission. The patient did not meet MCG criteria. 

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

The insurer's denial of coverage for the inpatient stay is upheld. Medical necessity is not substantiated.