Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Laceration. 
Treatment: Physician services. 
The insurer denied the Physician services. 
The denial is upheld. 

The patient is a male infant who sustained a laceration.  The parents contacted a nurse help line for a local urgent care who declined the patient due to the age and the increasing rise of COVID-19 cases that were spiking at that time. The parents also reached out to the pediatric practice who also indicated going directly to a plastic surgeon for primary repair.  The next morning, the patient was seen at the pediatrician's office who advised the patient to see an out of network plastic surgeon.  The patient and family immediately went to his office where a 2.6 centimeter full-thickness laceration of the left eyebrow was repaired surgically without any complications.  The operative report states that a two layered closure with dermal sutures, and external nylon sutures were utilized for the reconstruction. 

No, the proposed complex laceration repair was not medically necessary. 

The emergent medical care by an out of network provider is considered medically appropriate and indicated given the clinical scenario presented.  However, the complex level laceration repair has not been demonstrated in the operative report and should be adjusted to an intermediate level, repair. 

Based on review of the clinical information provided and comparison with the health plan, which is consistent with clinical practice standards and peer-reviewed literature established by the relevant medical community, the request for approval of the complex laceration repair for this patient is denied as not being accurate to the procedure that was performed.  The operative report included only states the dermal stitches were placed using a 5-0 Monocryl and then a 6-0 nylon suture was used to reapproximate the skin. This description of wound closure is consistent with an intermediate level closure and does not satisfy the requirements for a complex level closure.  Therefore, a complex level closure billing is not medically indicated and should be adjusted to an intermediate level closure based on the operative report documentation. 

In addition, the emergent nature of the closure is considered to be medically indicated and appropriate given the extenuating circumstances that were occurring at that time of the injury.  The history states that the patient initially reached out to the insurance nurse Hotline and was directed to a plastic surgeon because of the unusual circumstances of the COVID pandemic.  Because the child was so young and there was access to health care with limitations due to the pandemic, the best option for this patient was to obtain a private plastic surgeon for primary repair in the office to minimize the risk to the infant and other family members.  This extenuating circumstances prevailed again when the parents tried to obtain access to emergent care through the pediatrician office and the emergency department, which all declined to repair the traumatic laceration.  Therefore, in this situation emergent medical care for this patient is medically indicated.  However, the complex level laceration repair is not justified.  The codes should be adjusted and modified to an intermediate level code.  This reflects a standard of care established by the relevant medical community. 

Yes, the health plan act did act reasonably, with sound medical judgment and in the best interest of the patient as the patient did not have a complex laceration repair; he had an intermediate level closure.