Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left ulnar shaft and left 5th metacarpal neck fracture

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
According to the triage note the patient was s/p (status post) assault  with a blunt object and complained of abrasion on back of his head and left knee with right arm splinted. He was afebrile with stable vital signs. Orthopedics was called in consultation and noted left ulnar shaft and left 5th metacarpal neck fracture. It was also noted the patient denied loss of consciousness (LOC), numbness or tingling. The plan was x rays (electromagnetic radiation) of the extremities.

He was hit with bats and sustained injuries to his left forearm with onset of pain. He was brought to the emergency department (ED) and cleared for general trauma. He was evaluated for his ongoing forearm and hand pain. He denied prior injuries to his forearm or hand. He denied tingling or numbness, abrasion on the shin of his left forearm. Left arm revealed pain over his ulnar aspect of his forearm with soft compartments. There was pain and swelling of his fifth metacarpal with limited motion of his fingers secondary to pain. Medial, ulnar, radial nerves motor and sensory were normal. X ray views of his left hand showed an angulated fracture of the left fifth metacarpal neck. X ray of the left forearm showed a fracture of the ulnar shaft with displacement of short oblique. The plan was surgical intervention.  

He did well post op and was discharged for outpatient follow up.

Based upon the information provided, the hospital inpatient admission is not justified at the acute inpatient level as the patient should have been treated on observation level of care.  He did not need acute inpatient admission.  As per Milliman Care Guidelines (MCG) Health General recovery care 27th Edition: musculoskeletal disease GRG (General Recovery Care Guidelines): MG-MD (ISC GRG)  hospital admission is needed for appropriate care of the patient because of 1 or more of the following: Bone, joint, muscle, or orthopedic device infection (e.g. (for example), periprosthetic infection that requires inpatient care; Vertebral fracture that requires inpatient care (MEDICAL); Nonvertebral fracture, dislocation, or other musculoskeletal injury that requires inpatient care as indicated by Compartment syndrome (proven or cannot be ruled out during observation care), Major injury requiring inpatient care (nature of injury necessitates inpatient treatment or monitoring), severe pain requiring acute inpatient management; Rheumatologic disease (e.g., systemic lupus erythematosus, rheumatoid arthritis, spondylarthritis) exacerbation or related finding that requires inpatient care; Vasculitis with complications or findings that requires inpatient care; Severe crystal arthropathy (e.g., gout, pseudogout) that requires inpatient care; Rhabdomyolysis that requires inpatient care; Myopathy that requires inpatient care; Postamputation complication that requires inpatient care; severe pain requiring acute inpatient management due to musculoskeletal condition. 

This patient did not require inpatient admission based upon these criteria. He did not need inpatient hospitalization as this was a non-vertebral fracture that did not require inpatient admission but rather observation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.