Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head laceration.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is a teenaged female that presented to Mt. Sinai North in New York after being struck in the head above the left ear with a pickleball paddle which was thrown at her. The patient did not suffer loss of consciousness. The patient was alert with a Glasgow Coma Sore of 15 on arrival with normal vital signs. The patient was noted to have a laceration above the ear measuring 3 centimeters involving the antihelix. The laceration was debrided and repaired by the Plastic Surgery in the Emergency Department. Electrocardiogram (EKG) showed 1st degree atrioventricular (AV) block. Computed tomography (CT) scan of the head showed focal lateral frontal right calvarial streak artifact versus tiny frontal subdural hematoma. Neurosurgery evaluated the patient and recommended follow-up head computed tomography in 6 hours. The patient was admitted to acute inpatient level of care in a stepdown unit for treatment of acute head injury. The patient was recommended to receive antiseizure medication (Keppra) for 7 days and for neurological checks every 2 hours. Neurosurgery stated if follow-up computed tomography showed the findings were artifact, Keppra and neurological checks could be discontinued. The follow-up computed tomography showed no subdural hematoma or other abnormalities of the brain and the patient was subsequently discharged to home. The insurer denied the acute inpatient level of care stating that the patient could have been evaluated and treated in the emergency room or observation area. The hospital has appealed the denial of the acute inpatient level of care. The hospital's agent states "the rendered medical care was consistent with an inpatient level of care. The outcome could not have been predicted however the presenting symptoms support the physician's prudent decision to admit." This review is for an appeal of the denial of the acute inpatient level of care.

The requested health service, i.e. acute inpatient admission, was not medically necessary.

The patient was a teenage female that was struck in the head above the left ear with thrown pickleball racket. The patient denied loss of consciousness and was awake, alert, and oriented (Glasgow Coma Score of 15). Presentation at Mt. Sinai North Hospital demonstrated a laceration over the left ear which was repaired in the Emergency Department. Computed tomography (CT) of the head showed probable artifact versus small subdural hematoma on the side of the brain opposite the injury. Neurosurgery exercising caution recommended treatment for a subdural hematoma (Keppra and frequent neurological checks) and short-term follow-up computed tomography in six hours. Follow-up computed tomography in the morning (also the date of admission) confirmed the finding as artifact and the patient was discharged home. The patient had no clinical findings to suggest a significant head injury and caution prompted follow-up computed tomography for a probable artifact seen on the initial computed tomography. Based on the information known at the time of admission, and based on the evaluation, the patient did not require acute inpatient care. The care rendered was all consistent with a lower level of care. The evaluation and short-term monitoring could have been done within the framework of a lower level of care than acute inpatient. The care the child would have received at a lower level of care would have been identical to that which she in fact received. The patient could have been cared for at a lower level of care than acute inpatient.