Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Head injury
Treatment: Inpatient hospital admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is overturned.

The patient is a male infant born at term with no significant neonatal history who was taken to the emergency department (ED) after falling down stairs for an evaluation of an enlarging bump on his forehead. The father had been carrying the infant when he tripped. He put the baby down on the stairs, but the baby continued to fall down one to two stairs. The baby cried immediately with no loss of consciousness and no subsequent vomiting. He was taken to the ED for evaluation of the bump. He was swaddled at the time, so he had no other injuries. Level II Trauma was activated. Vital signs included a temperature of 98.3 degrees Fahrenheit, a heart rate of 220 beats per minute (bpm), and a respiratory rate of 32/minute. An examination was significant for the baby being alert, interacting appropriately with the caregiver, consolable, soft non-bulging fontanel, a small hematoma of the left forehead, no palpable bony skull defect, tachycardia, and a non-focal neurologic exam. A head computed tomography (CT) was obtained to rule out intracranial hemorrhage and was negative. An electrocardiogram was obtained because of tachycardia with concern for supraventricular tachycardia and was notable for a rate 219 bpm and the presence of P waves. Ice was applied to his face with no response. He was treated with Tylenol and was evaluated multiple times. The baby's heart rate decreased to the 190s bpm with intravenous (IV) fluids.

The baby was admitted to the Pediatric Intensive Care Unit (PICU) for monitoring following head trauma with tachycardia to 250 bpm (an incidental finding, refractory to pain medication and fluid resuscitation). Admission orders included frequent vital signs, neurology checks every two hours, continuous cardiorespiratory monitoring, Adenosine was available for a heart rate greater than 250 bpm, a repeat electrocardiogram in six hours, continuous pulse oximetry, IV fluids, regular infant diet if stable, Tylenol as needed, a social services consultation, and consideration for a cardiology consultation. Per cardiology recommendations, he was treated with Adenosine a total of three times, responsive each time. Propranolol was started, also per cardiology recommendation. He remained stable overnight with no further episodes of tachycardia. The baby was deemed stable for discharge to follow-up with cardiology and primary care.

At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination of medical necessity is overturned, in whole.

Yes, an inpatient hospital admission was medically necessary for this infant.

This infant sustained a moderate head injury due to his age, even without loss of consciousness. It was reasonable to monitor him for progression of symptoms. In addition to his head injury, he was noted to be persistently significantly tachycardic despite treatment for pain and IV fluids. An electrocardiogram was suspicious for supraventricular tachycardia. Vagal maneuvers were unsuccessful in conversion, so he was treated with Adenosine on three separate occasions, responsive to each dose with an appropriate decrease in heart rate. Because of concerns for possible Wolff-Parkinson-White (WPW), he was started on Propranolol. Cardiac conduction defects such as WPW are serious conditions with associated morbidity and mortality. Appropriate monitoring, evaluation, and treatment are essential. This level of care and the management required is most consistent with an acute inpatient level of care. Observation level of care is insufficient to appropriately manage such cases. This admission was medically necessary as an acute inpatient hospitalization.