Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple traumas.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
This is the case of a patient with a history of hyperlipidemia (HLD), hypertension (HTN, atrial fibrillation status post (s/p) ablation on Xarelto, loop recorder, and scoliosis, s/p fall at home presented to the Emergency Department (ED) having fallen down 6 steps and hitting her head. Her vital signs were stable. She complained of 5/10 constant aching right sided headache/facial pain and 6/10 constant aching low back pain. She had moderate right periorbital ecchymosis and edema and tenderness. Computed tomography (CT) of the spine was negative for cervical spinal compression fracture. Maxillofacial CT showed right periorbital soft tissue swelling with associated right inferior orbital wall and medial wall fractures. The ocular globes, lenses and optic nerves and extraocular muscles were unremarkable. CT of the abdomen /pelvis and chest showed buckling of the anterior left 4th and 5th ribs suspicious for non-displaced fractures. There was no intrathoracic or intra-abdominal injury. Chest x-ray (CXR) did not reveal suspicious focal airspace opacity. 

Plastic surgery saw the patient in consultation and noted that the patient had the injury the night before. The husband washed out the wound around the eye and the patient did not want to go to the ED that night. She awoke this morning with a swollen right eye and presented to the ED. On exam she had right periorbital ecchymosis with 3 centimeter (cm) lateral periorbital laceration through the orbicularis muscle and ecchymosis over the dorsum of the nose. The globe was intact, and vision was grossly normal. The plan was suture repair of the laceration and antibiotics with follow up in the office in 7-10 days. The surgeon performed in the ED, under local, a complex closure of a 3 cm laceration to the periorbital region under local anesthesia.

The patient was admitted to medicine/surgery service. Trauma surgery saw the patient. The plan was to admit to trauma telemetry with analgesia prn (as needed).

Neurology saw the patient because of headaches and noted that the magnetic resonance imaging (MRI) showed chronic infarcts and recommended no further inpatient intervention needed. Outpatient with neurology was recommended.

Trauma surgery progress note indicated the patient was doing well, and the plan was for discharge to home and to hold blood thinners. The patient was discharged.

Of note, the complete chart was not submitted for review.

Based upon the information provided, the hospital inpatient admission is denied, as the patient could have been treated on an observation status without an acute inpatient admission and should have been discharged sooner than she was. The patient did not meet criteria based the insurer criteria as well as national guidelines. 

There was no indication of need for inpatient admission as noted by Milliman Care Guideline (MCG) criteria. 

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

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