Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skull fracture.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
This case involves a child under review for an inpatient hospital stay. The emergency department note reported the patient was injured when he fell from a bike. The patient was not wearing a helmet and struck the back of his head. The patient was noted to have abrasions to his back, side, and face. Complaints included dizziness and vomiting. Imaging noted a right occipital non-displaced fracture extending into diastases of the adjacent lambdoid and occipital-mastoid sutures. The patient has been previously loaded with Keppra and transferred for further management. Examination noted swelling and abrasions. The patient was responding appropriately and following commands. The patient was admitted to the Pediatric Intensive Care Unit (PICU) for close monitoring. Magnetic resonance venography (MRV) of the head/brain revealed a filling defect at the right jugular foramen suspicious for non-occlusive thrombosis. The patient was discharged after consultation with neurology and stroke neurology. An appeal letter reported the patient was initially seen as a level 2 trauma transfer from outside the emergency department after a non-helmeted fall from a bicycle. The patient was found to have occipital skull fracture and possible subarachnoid hemorrhage. The patient was loaded with Keppra and transferred for higher level of care. After the initial fall from the bicycle the patient reported dizziness and multiple episodes of vomiting. The patient did report that he struck his head during the fall. The patient was initially admitted to the PICU and was evaluated by the trauma surgeon and neurosurgeon. Treatment included intravenous (IV) fluids, IV medications, and neurological checks every hour. It was noted during the hospital stay the patient had frequent vomiting 5-10 minutes after oral consumption requiring continued IV fluids and medication management. The patient was ultimately discharged home after the neurologist determined there was no emergency need for anticoagulation for the findings of nonocclusive thrombosis to the right jugular vein on MRV. 

Milliman Care Guidelines (MCG) recommends admission when there is hemodynamic instability, post resuscitation or presenting Glasgow coma scale score of less than 13, worsening of neurologic function post presentation, new focal signs on neurologic examination, new signs or symptoms that are severe, or persist despite observation care, altered mental status that is severe or persistent, evidence of increased intracranial pressure, new (or presumed new) intracranial pathology on imaging that requires intervention or monitoring beyond the observation care time frame, CSF (cerebrospinal fluid) leak, recurrent seizures, significant respiratory or cardiac abnormalities secondary to brain injury, and/or increased intracranial pressure or cerebral edema monitoring. 

In this case, the patient presented after a fall from a bike and known occipital skull fracture and possible subarachnoid hemorrhage. The patient received consultations and further imaging. The patient had persistent and worsening symptoms to include nausea with the inability to tolerate oral intake necessitating IV fluids and medications. There were also new findings of nonocclusive thrombosis to the right jugular vein on MRV. Therefore, treatment would require inpatient level of care.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the hospital admission is substantiated.