Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachycardia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial upheld.

This patient is a male alert but intoxicated patient who admitted to drinking on the night of presentation. He was exiting a taxi and tripped due to an unsteady gait and fell with his unprotected face, hitting the sidewalk. There was unknown loss of consciousness, a laceration was noted on the bridge of his nose and there was a medium-size hematoma in the frontal region of his skull.  He was protected with application of a cervical collar.  He denied nausea, vomiting, headache dizziness and incontinence.  He has a past medical history of hypertension.  He received intravenous (IV) fluids and benzodiazepines in the Emergency Department (ED) due to tachycardia.  He also had mild leukocytosis and lactate elevation.  In the ED, the patient's wound was dressed and the patient was given 1 Liter of Normal Saline.  The plan was to discharge the patient with an Ear, Nose & Throat (ENT) follow-up, but laboratory tests revealed a mildly elevated lactate and there was persistent mild tachycardia that did not improve with three liters intravenous (IV) fluids. Additionally, there was a mildly elevated white blood cell (WBC) count.  Because of this, the patient was given two doses of 25 mg Librium and IV lorazepam 1 mg. The patient received 1 Liter of Normal Saline with resolution of his lightheadedness. He was ambulating well and clinically sober.  The patient's discharge medications include aspirin, Lisinopril-hydrochlorothiazide, amlodipine, Coreg, Singulair and simvastatin.  At the time of discharge the patient was advised to follow up with ENT in 1-2 weeks.

Blood lactate is a useful tool for screening, risk stratification, and prognosis.  Peripheral venous and arterial values are interchangeable.  The initial value has prognostic significance, but serial measurements have more value for prognosis and for guiding therapy.  Lactate-guided therapy has been beneficial in some studies. In one study, reduction of blood lactate by 20% every 2 hr. for the first 8 hr. was associated with a decrease in morbidity and mortality.  The use of lactate clearance to monitor and guide therapy remains under investigation. (3) It is unknown whether lactate monitoring aimed to decrease levels during initial treatment in critically ill patients improves outcome.  Patients were randomly allocated to two groups. In the lactate group, treatment was guided by lactate levels with the objective to decrease lactate by 20% or more per 2 hours for the initial 8 hours of ICU stay.  In the control group, the treatment team had no knowledge of lactate levels (except for the admission value) during this period.  The primary outcome measure was hospital mortality.  The lactate group received more fluids and vasodilators.  However, there were no significant differences in lactate levels between the groups.

This patient was intoxicated and had a mechanical fall while stepping out of a taxicab. He fell and hit his face and sustained a laceration of his nose.  There is no evidence that the patient lost consciousness or had a seizure.  Multiple x-rays showed no evidence of fracture and his EKG showed no significant abnormalities.  

The inpatient hospital admission was not medically necessary since the patient could have been cared for in an observation unit setting.  The literature indicates that observation units are not just for patients that have chest pain or syncope, but can be tailored to follow other medical conditions such as was necessary for this patient. Therefore, the denial of coverage for the inpatient hospital admission should be upheld.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.