Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rib fracture with pneumothorax

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of a patient who presented to the emergency department (ED) status-post assault complaining of chest pain. As per the ED provider note the patient was hit in the back by a construction cone and was kicked and punched. The patient denied loss of consciousness (LOC). The patient complained of pain in their mid-back with breathing. The patient denied shortness of breath (SOB). Exam revealed the patient to be afebrile, with respirations of 18, and blood pressure (BP) 140/95. The patient appeared comfortable and nontoxic looking. The patient had no decreased breath sounds or wheezing. There was no tenderness on the chest wall. The patient had ecchymosis to the posterior right mid back with tenderness to palpation and no step off or obvious deformities. The patient's neuro exam was intact. The assessment was blunt trauma, and the plan was computed tomography (CT) of cervical spine, chest X-ray (CXR) and rib x-rays. CXR revealed no acute findings. X-ray of the ribs revealed nondisplaced right posterior 10th rib fracture and CT of the head and cervical spine were normal. A partially visualized right upper pneumothorax was seen on CT of the cervical spine. The plan was to obtain trauma consult and oxygen.

To approve this service the following InterQual 2022 Acute adult, general trauma, general criteria must be met: there must be a documentation of surgery planned within 24 hours and designated in an inpatient setting, bleeding actual or suspected with heart rate of 100-120 per minute, drop in BP with change of position, hemoglobin (Hb) and hematocrit (Hct) decreased within last 24 hours requiring a blood transfusion and Hb or Hct monitoring at least 2 times in 24 hours, or liver injury or spleen injury. In addition, there must be documentation showing the care needed could not be received in the ED for up to 8 hours and in an observation level of care up to 48 hours, and therefore admission in the hospital was required. 

These criteria are not met because the patient was admitted for chest and middle back pain associated with difficulty breathing. Based on the tests and services received, the insurer has made a decision that the patient did not need to be admitted in the hospital. The care could have been provided during an observation admission for up to 48 hours including repeat exams and other diagnostic testing and monitoring to determine a diagnosis and a determination of need for admission. 

As per Milliman Care Guidelines (MCG) Health Guidelines General recovery care 27th Edition: Rib fracture ORG: M-545 (ISC) admission is indicated for 1 or more of the following: hemodynamic instability; Flail chest, etc. This patient did not have a significant rib fracture; did not have pain which limited their ability to clear their airway; and apparently did not have a pneumothorax of any significance as repeat CXR did not show a pneumothorax. The patient was observed/monitored, all of which should have been done without an acute inpatient admission. Therefore, this patient did not meet guidelines for admission but rather observation followed by discharge. 

Finally, MCG Health Inpatient and Surgical Care 27th Edition: Rib fracture: observation care ORG: OC-0-59 (ISC) notes that observation care is indicated for 1 or more of the following: Pain persistent despite emergency department care; Dyspnea or tachypnea; vital sign abnormality, etc.  Thus, in this case all that the patient required was observation care as the injury was not severe to require inpatient admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.