Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Head injury.
Issue under review:  Inpatient admission.

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

No, the proposed inpatient admission was not medically necessary.

The patient is a male child with complex medical history including late preterm birth at 37 weeks' gestation, seizure disorder diagnosed at three months of age, milk protein allergy, autoimmune disorder, and immunodeficiency that fell from a ride landing on a hard surface.  He fell from a height of approximately four feet and hit his forehead.  He was unresponsive for three to five minutes.  His mother applied ice to the swelling on his forehead and took him to an emergency department.  He was evaluated and treated with Tylenol.  The mother left because she did not want a head CT and returned to a different emergency department about four hours later after applying ice for several hours, noting that he was not as active.  Additional history included several-week history of fevers and diarrhea, visit to the pediatrician that morning for lab work, history of hypogammaglobulinemia and low T cells, history of sleep apnea, and recurrent Clostridium difficile (C. Diff) infections.

Vital signs included temperature 36.8, heart rate 123, respiratory rate 32 with 99% saturation in room air, and blood pressure 123/53.  Examination was significant for a small rash from the electrocardiogram (ECG) leads from the previous hospital, reactive pupils, moist oral mucosa, regular heart rate and rhythm, clear lungs, benign abdomen, and non-focal neurologic exam.  The case was discussed with the child's pediatrician who noted multiple inconsistencies in the mother's story/history including C. Diff infections, history of autoimmune disorder, and fevers not documented anywhere but at home.  The pediatrician recommended admission for 24-hour observation. 

Additional history at the time of admission included recent fall from a highchair two weeks prior and a grand mal seizure one and a half months prior.  Admission examination noted a three-centimeter (cm) area of soft tissue swelling on the left forehead.  Admission orders included vital signs per protocol, consideration for head CT if any acute changes, and Similac Alimentum (his usual diet).  The following day, the patient was noted to be alert and playful, at behavior baseline, per the mother.  No further testing was ordered, head CT was not recommended.  He was deemed stable for discharge following evaluation by his pediatrician.  Prior to official discharge, Social Work was consulted because the mother was threatening to leave against medical advice (AMA) in order to make an appointment.  Security was contacted to assist, and the discharge proceeded uneventfully.  The pediatrician recommended referral to Child Protective Services.

This child could have been safely managed at a lower level of care.

The majority of traumatic brain injuries (TBI) in patients presenting to the ED are considered to be mild, as defined as Glasgow Coma Scale (GCS) 14 or GCS 15 with less than five minutes loss of consciousness or alteration in memory or alertness.  Management is based on risk stratification.  Patients at low risk for intracranial injury are either asymptomatic or have the following symptoms:  headache; dizziness; scalp hematoma, laceration, contusion, or abrasion; no moderate or high-risk criteria; and no history of loss of consciousness.  Symptoms consistent with moderate risk of intracranial injury include the following: history of change or loss or consciousness on or after the injury; progressive headache; alcohol or drug intoxication; post-traumatic seizure; unreliable or inadequate history; age less than two years unless trivial injury; vomiting; post-traumatic amnesia; signs of basilar skull fracture; multiple trauma; serious facial injury; possible skull penetration or depressed fracture; suspected child abuse; and significant subgaleal swelling.  Findings consistent with high risk of intracranial injury include: depressed level of consciousness not clearly due to alcohol, drugs, metabolic abnormalities, or postictal; focal neurological findings; decreasing level of consciousness; and penetrating skull injury or depressed fracture.  Patients in the low-risk group may not need a CT scan.  They may meet criteria (not included here) for observation at home.  There are no strict guidelines for disposition of patients presenting to the ED with mild TBI.  Certainly patients with vomiting that require intravenous (IV) hydration, patients with altered level of consciousness, and patients with intracranial pathology must be admitted for monitoring and treatment.  Patients with underlying chronic medical conditions may also benefit from a period of observation, particularly if they are not able to communicate sufficiently.

This young child with complex medical history, discrepancies in his clinical and current history, recent fall from his highchair two weeks prior, and current fall to a hard surface with apparent loss of consciousness presented to a second ED for evaluation.  He was reportedly less active than usual but had no vomiting and was acting in an age-appropriate manner in the ED.  Because of his medical history, the fact that this was his second fall in two weeks, and the discrepancies in his history, it was reasonable to monitor him in the hospital for any changes or deterioration.  However, he was overall hemodynamically stable, with no vomiting, and no observed behavioral changes.  He did not require acute inpatient admission and could have safely been managed at a lower level of care.