Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Accidental fall.
Treatment: Inpatient Admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is a female with autism, who fell striking her head on concrete stairs while being carried in caregivers' arms. She cried immediately and there was no reported loss of consciousness. She had normal and age appropriate behavior, including crying, but consolably, in the hospital. There was no vomiting. Her neurologic exam was normal. She had a normal blood count. Liver enzymes, kidney function, and electrolytes were obtained. She did not have neuroimaging. She had a normal chest and abdominal x-ray. She was admitted to the pediatric intensive care unit and received hourly neuro checks until discharge. 

According to Nigrovic et al. (2019), it is noted that "Available traumatic brain injury (TBI) prediction rules can assist with CT(computed tomography) decision-making by identifying patients at either low risk for TBI, for whom CT scans may safely be obviated, or at high risk, for whom CT scans may be indicated. For clinical prediction rules to change practice, however, they require active implementation. Observation before CT decision-making in selected patients may further reduce CT rates without missing children with clinically important TBIs."

"Blunt traumatic brain injury (TBI) is a disruption in the normal function of the brain caused by a mechanical impact to the head. TBI ranges from mild to severe and/or fatal. TBI can be conceptualized as a primary event occurring at the moment of impact, followed by secondary damage due to edema and elevated intracranial pressure. Early identification and management of traumatic brain injury are crucial in halting the progression of the primary insult and preventing or reducing secondary brain injury. TBI is typically classified as mild, moderate or severe, based on the Glasgow coma scale (GCS). Patients with a GCS of 14 to 15 are considered to have mild TBI, while patients with a GCS of 9 to 13 have moderate TBI, and those with a GCS of 3 to 8 have severe TBI.[1] Initial symptoms of moderate-severe TBI in children are similar to adults, but the ultimate functional impact in children who survive TBI becomes more apparent as the child ages and faces increased challenges in processing information, reasoning, and impaired judgment." (Haydel, M.J. & Saeed, W. 2020)                                                       

This patient was not hemodynamically unstable, did not have an abnormal Glasgow score or neurologic exam, did not have elevated intracranial pressure, or abnormal computed tomography imaging. She did not have a cerebral spinal fluid leak, a significant other injury, or a depressed skull fracture. She did not have a post-traumatic seizure. She did not have severity or persistence of abnormal findings that would preclude an observational level of care. Her home environment was safe for discharge and the treatment/ monitoring she required did not exceed that which could be provided at an observational level of care.      

This patient required observation, but did not need an acute, inpatient level of care. She was hemodynamically stable, did not have abnormal neurologic findings and did not receive neuroimaging. 

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

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