Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Rim Fracture 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was upheld. 

This patient is a male child who presented to the Emergency Department (ED) via emergency medical service (EMS) after being struck by a low speed motor vehicle. He was alert and oriented; it was unclear whether or not the patient had a loss of consciousness. He had complaints of right knee pain and right facial abrasion with a hematoma noted on his right parietal region.  He had a computed tomography (CT) of the brain that showed no acute intracranial hemorrhage, mass effect or acute osseous fracture. It was reported that he had a small pelvic rim fracture but was able to weight bear and ambulate without assistance. He was consulted by pediatric orthopedics with recommendations for pain control, weight-bearing as tolerated with physical therapy (PT) and occupational therapy (OT). No acute orthopedic surgical intervention was recommended.  He was admitted for pain management and antibiotic therapy for a sinus fracture. He had an episode of hematuria and was evaluated by Urology. A computed tomography (CT) of the abdomen was performed there was no evidence of renal collecting system injury. The patient was medially stable and discharged home the next day. 

According to Milliman Care Guidelines Traumatic brain injury, nonsurgical treatment: observation care Inpatient and Surgical care 23rd Edition: ORG: OC-063 (ISC) observation may be appropriate for patient with head injury and 1 or more of the following: vital signs abnormality; altered mental status; temporary loss of consciousness at time of injury; suspicion for vascular injury (e.g., penetrating injury, soft tissue swelling of the anterior neck); dizziness or vomiting beyond immediate post-injury period; posttraumatic seizure; presence of elevated intracranial pressure or cerebrospinal fluid leak suspected (monitoring needed beyond usual 3 to 4 hour time frame for emergency department care); intracranial infection suspected; extracranial injuries or wounds that require care beyond that provided in emergency department; non-depressed, non-basilar closed skull fracture; pain that cannot be managed on outpatient basis; head injury in patient older than 65 years; anticoagulant treatment before injury; patient suspected or known to be intoxicated (e.g., from alcohol, opioids, other drugs of abuse); child whose situation includes 1 or more of the following: clinical response to outpatient therapy uncertain or outpatient supervision by parents or caregivers uncertain; other observation care needs. In this case, observation was all that was required and not inpatient admission.

Furthermore, as per MCG Health General Recovery Care: Multiple Trauma GRG GRG: PG-MTR (ISC GRG), hospital admission is indicated when patient with significant multiple trauma requires inpatient care for 1 or more of the following: Major surgical and post-procedural care; nonoperative care of significant injury. In this case, there was no indication for admission based upon these criteria. 

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

Based on the above, the medical necessity for the inpatient hospital stay is not substantiated.  The insurer's denial is upheld.