Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Burn to the face and hands.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

According to the emergency room (ER) provider note, this patient presented to the ER with burns to face and right hand after propane tank explosion while at work. The patient has had significant burning/sensation since then. The patient denied headaches, dizziness, and visual changes. On exam, vital signs were stable. Head, eyes, ears, nose and throat (HEENT) exam revealed no singed nares. Pupils were equal, round and reactive to light. There was a superficial flame burn to the face and right hand. Burn service was called.  

Burn service admission note indicated the patient had a flame burn to the face, bilateral dorsal hands and right ear. The flame was in contact with the skin skin for 1-2 seconds before the patient withdrew and immediately poured cold water on themselves and presented to the ER. The pain was 10/10 and the patient's eyes were especially painful. The patient denied changes in vision or loss of consciousness (LOC). Exam revealed skin to show pink edematous skin of face, right ear, right dorsal hand and quarter sized area of left dorsal hand. Eyebrows and eyelashes were singed. There was periorbital edema with no evidence of retinal hemorrhage. There was limited active range of motion (ROM) to the right hand. There were palpable pulses; fingers were warm and well perfused. The assessment was 0% total body surface area (TBSA) superficial flame burn to face, bilateral dorsal hands, and right ear from gas stove. The plan was labs, wound care with bacitracin, pain control, ophthalmology consult and burn physical therapy and occupational therapy (PT/OT).

Ophthalmology saw the patient and noted the history of flame burn. The provider also noted the diplopia, flashes and only mild blurring of vision due to tearing. The assessment and plan was anterior exam status post facial and lid erythema and edema, with singed eyebrows and lashes. The plan was erythromycin ophthalmic ointment, artificial tears and that the patient should follow up after discharge with ophthalmology service.

The patient was discharged.  As per discharge summary, the patient had no events overnight and the swelling was unchanged on exam the next morning and the patient was without new ocular complaints. The patient was cleared for discharge both by burn and ophthalmology service with follow up in 1 week. 

The patient was stable and could have been observed and discharged without an acute admission but rather a 23-hour observation stay. As per Milliman Care Guidelines (MCG) Health Inpatient and Surgical care 27th Edition Burns, Major ORG: M-615 (ISC) admission is indicated for 1 or more of the following: Hemodynamic instability; Full-thickness (third-degree) burn; Deep partial-thickness (second-degree) burn greater than 10% of total body surface area; Deep partial-thickness (second-degree) burn of face, hand, foot, genitals, or perineum; Deep partial-thickness (second-degree) burn that crosses major joint or is circumferential; Inhalation injury; Burn accompanied by other significant medical problems or injuries (e.g., altered mental status, arrhythmia, inability to maintain oral hydration, significant wound or fracture); Serious chemical burn; High-voltage (e.g., 1000 volts or more) electrical burn; Pain management requiring inpatient care (e.g., intravenous (IV) narcotics).  Thus, this patient had no indications based upon these criteria for an admission but rather observation. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient is not substantiated.