Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is the case of an adult male with no significant medical history who presented to the emergency department (ED) with complaints of left facial pain after being assaulted. As per the ED triage note, the patient presented with stable vital signs after being assaulted. He was brought by emergency medical services (EMS). The patient was alert, oriented and reported that he was drinking at a bar when he was assaulted. The patient had blood-stained teeth and swelling to his left face with left sided facial pain. As per the ED provider note, the patient was jumped by 3 men and was punched. The patient denied loss of consciousness (LOC), neck pain weakness, and numbness. The patient admitted to alcohol use. On exam, he appeared in mild distress with extra ocular muscles intact (EOMI). Computerized tomography (CT) of the head showed a mandibular fracture. Trauma consult was obtained and noted the patient was to be admitted for plastics/surgical repair. CT of the head was negative for intracranial pathology. Maxillofacial CT showed anterior and left mandibular fractures. As noted by the surgical attending, the patient was hemodynamically stable and had no LOC. The workup in the ED was negative except for anterior fracture of mandible, non-displaced; less obvious was left sided mandibular fracture as well. The plan was for plastics to take him to the operating room (OR) that same day for fixation of fractures. He was cleared from the trauma surgical service. The patient left the facility against medical advice (AMA) before the surgery could be performed.

The patient did not have one or more of the following: abnormal vital signs as indicated by 1 or more of the following: vital sign abnormality not readily corrected by appropriate treatment, as indicated by 1 or more of the following: tachycardia; hypotension, orthostatic hypotension; vital sign abnormality that is severe; vital sign abnormality leading to inadequate systemic perfusion as indicated by high fever or other high risk infection situation; outpatient and observation care antimicrobial treatment unavailable; bacteremia; temperature greater than 104.9 degrees or less than 95 degrees. These criteria are not met because a review of the records shows that the patient could have been placed in observation under monitoring, had an evaluation, had testing and been treated symptomatically while awaiting test results. Consultation with other professionals could also be done in observation. There was no hemodynamic, pulmonary, neurological or metabolic reason for acute level of care. The services and interventions provided could have been done in the observation setting. There were no positive or other findings after evaluation by the doctors that would have required an acute level of care. The patient could have been kept in observation according to guidelines and with negative test results and improved symptoms, discharged from observation with an ambulatory plan of care. This decision was made under New York State (NYS) social services law section 364-j(4)(k).

Pain was managed. Intravenous (IV) Cefazolin was given. Head of bed was kept elevated with ice applied to face as needed for pain/swelling. The patient was optimized for surgical intervention however patient expressed concern and agitation over waiting for OR Time. The team explained to patient he was placed on OR Schedule as an add-on however he remained upset. Prior to receiving any further care, the patient decided to leave AMA. The patient's decision to leave AMA in no way negated the medical necessity of this inpatient admission. The patient met guidelines for admission based upon Milliman Care Guidelines (MCG) Head and Neck surgery or procedure GRG (SG-HNS). 

The patient could have been treated on an observation status without an acute inpatient hospital admission. The patient did not meet criteria based on the insurer's criteria as well as national guidelines.

This patient did not have any of these indications as he had no neurologic findings and did not have a complex fracture and did not have an orbital fracture or any other for acute inpatient status. He could have been treated as a 23-hour observation. 

There was no indication of need for inpatient admission as noted by MCG guidelines. 

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

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