Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head injury. 
Treatment: Inpatient admission. 

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

The patient is a girl who was admitted to the hospital after her mother discovered a soft spongy spot on her scalp during a bath, as well as slight bruising on her forehead. The patient mother's informed the patient had run into a door, after which she cried for a minute and then returned to playing. Upon further questioning, the mother reported the patient had fallen out of her crib on a previous night and was crying afterwards, but the lump on her head was not noticed at that time.  The mother reported the patient was clumsy and fell a lot. The parents denied any lethargy or change in the patient's behavior. 

On exam, the patient was noted to be alert and oriented, happy, and playful. Review of system was negative for headaches.  A spongy soft spot was noted at the left parietal scalp about the size of half a palm, and there was a faint ecchymotic area to the left forehead. No scalp swelling was noted.  A computed tomography (CT) scan showed no acute intracranial abnormality. There was slight hyperdense soft tissue lesion within the scalp over the left posterior frontal area, possibly representative of a hematoma, epidermoid cyst, or vascular malformation. The attending physician highly encouraged observations on the pediatric floor overnight, but that the patient could be followed up as an outpatient if the parents wanted to take that route.  The patient was admitted for observation with a working diagnosis of skull fracture, with plans for Keppra and neuro checks. A repeat computed tomography (CT) scan was to be performed only if there was a change in her mental status. 

The patient was cleared by the pediatrician and a social worker, and it was determined no acute neurosurgical intervention was needed. It was noted that it was less likely a bleed would evolve as the trauma was more than 12 hours prior. Mental status and continued neuro checks were done. The patient was cleared for discharge, with instructions to follow-up as an outpatient in two weeks to evaluate for left meningeal cyst. She was prescribed a seven-day course of Keppra. 

No, the proposed treatment was not medically necessary. 

The acute inpatient admission was not medically necessary. The patient was reported to sustain minor head trauma, without any intracranial pathology on computed tomography (CT) of the head and without any neurological deficits on exam. The trauma took place more than 12-24 hours prior to the emergency room visit. Considering that there was no evidence of brain contusion, concussion, subarachnoid hemorrhage, subdural hemorrhage, cortical or subcortical injury, the hospital admission is not in accordance with generally accepted standards of medical practice and is not clinically appropriate. There is no credible scientific evidence in peer-reviewed medical literature to support acute inpatient admission under the member circumstances. Therefore, this treatment was not medically necessary. 

The patient had normal neuroimaging and normal exam and did not require acute inpatient admission.