Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-displaced mandibular symphysis fracture 
 
Treatment: Inpatient Hospital Admission

The insurer denied the Inpatient Hospital Admission. The denial was reversed. 

This is a male patient who presented to the emergency department (ED) after a syncopal episode at home. He had complaints of pain in his jaw and a laceration on his chin. Plastic surgery consulted on the patient. A computerized tomography (CT) of his head revealed no intracranial injury. There was a non-displaced mandibular symphysis fracture extending between the central incisors. He had bilateral mandibular condylar head fractures with extension in the TMJ's displaced on the left.  CT of his cervical spine was negative. The patient was given antibiotics and surgery was scheduled. He had an open reduction internal fixation (ORIF) of mandibular symphyseal fracture, closed reduction of bilateral condyle fractures, placement of intermaxillary fixation.  The experienced no post-operative complications. He was started on a clear diet and advanced to a full; chewing was discouraged. The patient was safely discharged home when medically stable. 

As per MCG Health General Recovery Care Ambulatory Surgery Exception Criteria GRG: CG-AEC (ISC) a potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Preoperative situation, condition, or finding that warrants inpatient stay as indicated by one or more of the following: Inpatient care needed for preoperative disease or condition: Emergent procedure, Complex surgical approach or situation anticipated, Procedure is not low risk and patient at high anesthetic risk, Presence of drug-related risk, Inadequate outpatient care situation.  The patient therefore required inpatient acute admission in this case as the patient did require extensive emergent surgery for a complex fracture.

Furthermore, according to MCG General Recovery Care 23rd Edition Head and Neck Surgery or Procedure GRG GRG: SG-HNS (ISC GRG) Operative Status Criteria Ambulatory surgery examples include: Most eye, middle ear, inner ear, or nose surgeries; Some pharyngeal airway procedures for sleep apnea; Most biopsy procedures; Most simple drainage procedures without drain in place; Most major dental procedures; Operations for hearing loss; Cleft palate or lip operations; Most vocal cord operations; Many cyst or sinus remnant operations; Epistaxis control with ALL of the following: No posterior packing, No procedures endangering airway; Tonsillectomy or adenoidectomy (or both) without complication (e.g., hemorrhage). Inpatient surgery includes other surgeries and procedures, and an inpatient stay will usually be needed for one or more of the following: Inpatient procedure: Head and Neck Surgery or Procedure; Procedure is usually performed on ambulatory basis, but inpatient stay is needed. 

This patient did have the indication above that would have required inpatient admission rather than just observation as he required emergent exploratory surgery which required monitoring post-op to assess if he could eat and to assess respiratory status.  The insurer was wrong to use the other Head and Neck guidelines as this patient required emergent surgery.

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.