Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rib fractures

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission

The denial is upheld

This is the case of a male with a PMHX (primary medical history) of alcohol abuse and a seizure who presented to the ED (emergency department) with left sided chest pain after a sustained fall. As per the ED provider note, the patient was seen in the ED the day prior with complaint of left rib pain on deep inspiration. A CXR (chest x-ray) was obtained by the attending however the patient signed out AMA (against medical advice) before the x-ray results. The CXR revealed multiple left rib fractures of the sixth through the 10th left ribs with a probable tiny apical left pneumothorax. The patient was recalled to the ED for evaluation of a closed fracture of multiple ribs on the left side. 

To approve this service, InterQual 2021 acute adult general trauma and musculoskeletal criteria must be met as follows: facial fracture with the inability to take anything by mouth and the need for fluid through the vein; subluxation or fractured spine, a fractured thigh bone, hip, or pelvis, and not a surgical candidate; or dislocation of the spine or major prosthesis and either a need for pain medication 3 or more times within 24 hours or continuous fluids by vein, pending medical clearance for surgery within 24 hours ; or the need for a traction (screws and/or pins used to align broken bones while healing). These criteria were not met because: the patient was admitted for evaluation and management of multiple rib fractures on the left side. Based on the tests and services received, the insurer feels that the patient did not need to be admitted in the hospital. The insurer feels that the patient could have been observed and treated up to 48 hours with repeat exams including labs and other diagnostic testing and monitoring to determine a diagnosis and a determination of need for an admission. Severe medical problem warranting an inpatient admission was not established. The hospital admission was not medically necessary. 

According to MCG (Milliman Care Guidelines) Inpatient and Surgical care 26th Edition: Rib fracture ORG: M-545 (ISC) Admission is indicated for 1 or more of the following: hemodynamic instability; flail chest; acute respiratory failure (e.g., mechanical ventilation needed or imminent); new hypoxemia; pain (e.g., inhibiting ability to cough or clear airway) that requires inpatient treatment (e.g., not controllable in observation care, outpatient regimen cannot be established); injury (e.g., intra-abdominal, vascular, neurologic, pneumothorax) identified that requires inpatient care; rib fracture associated with infection that requires inpatient care (e.g., pneumonia too severe for outpatient treatment); tachypnea that persists despite observation care; immediate inpatient surgery needed (e.g., for a displaced rib fracture). This patient did not have flail chest; did not have pain which limited his ability to clear his airway; did not have a pneumothorax as shown on CT (computed tomography) scan of the chest or other major injury; and he did not require surgery. In fact, this patient went home and was called back because of x-ray findings only. He was observed/monitored, all of which could have been done without an acute inpatient admission. Therefore, this patient did not meet guidelines for an admission but rather for observation followed by discharge. 

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

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