Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post (s/p) Motorcycle accident
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male. He was transferred the facility under review from another facility after sustaining injuries in a motorcycle accident. The patient was brought to the hospital by a friend. The patient reported he had been riding a skateboard, but it was later learned that the patient was in fact riding a motorcycle and had crashed into a parked car. The patient reported pain in torso, hands, left wrist, ribs and face. The worst pain was reported in the left wrist. The patient reported drinking alcohol prior to the accident and that he was unconscious.

The patient's vital signs on arrival were blood pressure 92/54, pulse 92, respiratory rate 18, and oxygen saturation 100% on room air. Injuries sustained were bilateral nasal bone fractures, bilateral non-displaced rib fractures (4, 5 on the right and 3, 4 on the left), non-displaced left distal radius metadiaphysis fracture, possible pulmonary hemorrhage, and road rash. His blood alcohol level was markedly elevated at 251. The patient was administered intravenous fluids and pain medication at the transferring facility with normalization of vital signs prior to transfer. CT (computed tomography) of the abdomen was negative. CT (computed tomography) of the cervical spine showed no injury. CT (computed tomography) of the chest showed rib fractures and questionable pulmonary hemorrhage. The left arm was splinted in the ER (emergency room) prior to transfer. The patient had normal mental status throughout.

The patient was admitted to acute inpatient level of care. The patient was ordered for regular diet which he tolerated. The following morning, the patient was alert and oriented and complaining of left knee pain. Orthopedic Surgery determined that there was no surgery indicated for the left rib fracture. The plan was to discharge the patient home after evaluation by Physical Therapy and a knee x-ray. Knee x-ray showed no fracture or dislocation. The patient was evaluated by PT/OT (physical therapy/occupational therapy), and recommendations made for home. At the time of discharge, the patient was tolerating regular diet, ambulatory, and had pain well controlled on oral medication.

The patient was discharged from the hospital the following day. Total inpatient hospital time was less than 12 hours.

The acute inpatient level of care was denied as not being medically necessary. This review is for an appeal of that denial.

An appeal letter from the patient's father states his son had severe and catastrophic injuries, and that his son was not capable of making decisions related to medical care or appropriateness of transfer to the other facility. An appeal from the hospital states the decision to admit was made by the trauma physician specialist and that based on their clinical judgment, the inpatient admission was justified.

No, the Inpatient admission was not medically necessary.
The patient is a male who sustained injuries in a motorcycle accident. The patient was brought by a friend to one facility and then transferred to another facility.  The patient was intoxicated. Vital signs on arrival at the initial hospital showed hypotension with a blood pressure of 92/54 without tachycardia. Other vitals were normal. Mental status was normal. Blood pressure normalized with fluid. The patient underwent multiple scans. There was no injury to the cervical spine or abdomen. Injuries sustained were bilateral nasal bone fractures, bilateral non-displaced rib fractures (4, 5 on the right and 3, 4 on the left), non-displaced left distal radius metadiaphysis fracture, possible pulmonary hemorrhage, and road rash. Blood alcohol level was markedly elevated at 251. The patient was administered intravenous fluids and pain medication at the transferring facility with normalization of vital signs. CT (computed tomography) of the abdomen was negative. CT (computed tomography) of the cervical spine showed no injury. CT (computed tomography) of the chest showed rib fractures and questionable pulmonary hemorrhage. The left arm was splinted.

Upon arrival the second facility, the patient was admitted to acute inpatient level of care. The patient was ordered for regular diet which he tolerated. The morning note states the patient was alert and oriented and complaining of left knee pain. Pain was well controlled with Lidoderm patches and the patient refused narcotic medication. Orthopedic Surgery determined that there was no surgery indicated for the left wrist fracture. The plan was to discharge the patient home after evaluation by Physical Therapy and a knee x-ray. Knee x-ray showed no fracture or dislocation. The patient was evaluated by PT/OT (physical therapy/occupational therapy), and recommendations made for home. At the time of discharge, the patient was tolerating regular diet, ambulatory, and had pain well controlled on oral medication.

The patient's most significant injury was bilateral rib fractures. There was no solid evidence to support and underlying pulmonary contusion. Pain control did not require narcotic medication. The patient was alert and oriented. The wrist fracture was non-displaced and did not need surgery. The care rendered did not require an acute inpatient level of care. It could have been rendered at a lower level of care. If patient did not meet discharge parameters after 24 hours, he could have been upgrade to acute inpatient. Total inpatient hospital time at the second facility was less than 12 hours. The care rendered was amenable to a lower level of care, e.g. observation. The care the patient would have received at a lower level of care, e.g. observation, would have been identical to that which he in fact received.

The patient could have been treated at a lower level of care without compromise of patient safety.

The patient suffered a broken nose, bilateral rib fractures, and a non-displaced fracture of the left wrist. The patient was transiently hypotensive but was always normotensive with normal vital signs after arrival at the second facility. He was hemodynamically stable. Imaging studies showed no injury to the cervical spine, abdomen, or pelvis. The only treatment for the rib fractures was pain control and for the left wrist, splinting with outpatient follow-up.  The patient was cleared for discharge by physical therapy and was ready for discharge within 12 hours of admission.  The care the patient received could have been at a lower level of care such as observation level of care. The anticipated length of stay should have been no more than one past-midnight stay from the time the decision to admit was made. As of later in the morning and on the same date of admission, the patient was hemodynamically stable with good pain control, tolerating regular diet, and ambulatory. Acute inpatient level of care is not the appropriate level of care for this diagnosis or this patient's care. It is in excess of the level of care which is necessary to provide safe treatment.

Regarding the appeal letter from the patient's father stating his son had severe and catastrophic injuries, and that his son was not capable of making decisions related to medical care or appropriateness of transfer to the second facility, this is irrelevant to acute inpatient care, nor were the injuries considered catastrophic.  An appeal from the hospital states the decision to admit was made by the trauma physician specialist and that based on their clinical judgment, the inpatient admission was justified. No reason is given why the care rendered could not have been at a lower level of care. These issues could have been adequately addressed at a lower level of care. A significant injury was not suspected based on extensive imaging studies. The care the patient would have received at a lower level of care would have been identical to that which he in fact received without compromise of the quality of care rendered or patient safety.