Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Broken Ribs
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an elderly male that sustained rib fractures to the right third and fourth ribs and a small pneumothorax after tripping over an object while jogging, and landing on his chest. It is unclear whether or not the patient hit his head (conflicting notes). He denied loss of consciousness. The patient was taking Tylenol and ibuprofen at home for the pain. The patient was seen by his primary care provider two days later who obtained a chest x-ray showing a rib fracture. The patient was referred to South Nassau 
Communities Hospital to obtain a computed tomography scan of the chest. The patient did not complain of chest pain. He was not tachypneic and had normal oxygen saturations at presentation. 
Chest x-ray at South Nassau showed no change in the pneumothorax compared to the previous day. Computed tomography scan showed a small right-sided pneumothorax, displaced rib fractures (three and four) and incidental finding of several subcentimeter pulmonary nodules. The patient was initially placed on 100%9(percent) non-rebreather oxygen for the pneumothorax which was subsequently decreased to two liters by nasal cannula. No chest tube was placed and was deemed unnecessary. Follow-up chest x-ray four hours later showed no change in the small pneumothorax. Past medical history was significant for COVID infection three weeks prior. The patient was admitted to inpatient level of care on Trauma Telemetry. The patient received Lidoderm patch for pain and non-steroidal anti-inflammatory medication. The patient reported pain with cough but otherwise did not report significant pain. Physical Therapy saw the patient on the next day and recommended no further therapy and cleared for discharge. The patient was discharged home on hospital day number two.
The acute inpatient admission was denied as not medically necessary. The hospital has appealed the denial of the acute inpatient admission. The hospital's appeal states that both the Emergency Department Attending and Trauma Surgeon recommended inpatient level of care as there was no improvement in the pneumothorax despite non-rebreather oxygen. Inpatient care included telemetry monitoring, oxygen therapy, pulse oximetry, incentive spirometry, pain management, serial chest x-rays, Lovenox, neurological assessment and physical therapy. The hospital cites Milliman Care Guidelines health guideline for rib fractures requiring inpatient care: "Injury (e.g., intra-abdominal, vascular, neurologic, pneumothorax) identified that requires inpatient care."

The inpatient level of care was not medically necessary. 

The patient could have been treated at a lower level of care. Acute inpatient admission was not necessary. The patient presented two days after injury. The pneumothorax was small and was stable. The patient did not have tachypnea or low oxygen levels. The patient had controlled his pain since the accident with Tylenol and ibuprofen. In the hospital, pain management was with a Lidoderm patch and anti-inflammatory non-narcotic medication. Oxycodone was ordered but never requested by the patient and was not given. The care rendered did not require inpatient level of care.