Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall with head injury. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a male patient who initially presented to the emergency department with disorientation following a fall with a head injury. He had no pertinent medical history. The initial examination documented the patient as awake, alert and disoriented.  A coronavirus disease 2019 (COVID-19) polymerase chain reaction (PCR) swab was positive. An electrocardiogram (EKG) revealed sinus tachycardia. A chest x-ray (CXR) was unremarkable. A computed tomography (CT) scan of the head revealed no evidence of acute intracranial hemorrhage, mass effect, or large acute territorial infarction. It did note a right lateral parietal scalp swelling / hematoma. Fluid resuscitation was provided with an improvement in the tachycardia. The emergency department physician documented a low suspicion for meningitis. Empiric antibiotics were initiated and the patient was admitted to the hospital. 

The admitting physician had an impression of sepsis secondary to a viral infection with plans to rule out meningitis. Neither Remdesivir nor dexamethasone were felt to be indicated for the COVID-19 infection. A lumbar puncture was pursued, however, while in the radiology suite the patient and patient's mother declined the procedure as the patient was clinically improving. An electroencephalogram (EEG) was unremarkable. There were no new issues. The patient felt well. He was able to recall interactions with the nurse as well as what he ate for breakfast. Blood cultures werenegative. Neurology recommended to discontinue Keppra and cleared the patient for discharge if the magnetic resonance imaging (MRI) of the brain was unremarkable. The magnetic resonance imaging (MRI) of the brain was performed and was essentially unremarkable. The patient was discharged with a working diagnosis of post-concussive syndrome. Inpatient emergency admission was denied by the health plan and is under review for medical necessity. 
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care. 

The patient had no significant medical history and presented to the emergency department with confusion following a fall with a head injury. Initial evaluation revealed a fever of 101.8 degrees Fahrenheit, tachycardia, brief hypotension, and a positive COVID-19 PCR test. A chest radiograph and CT scan of the head imaging were unremarkable. Treatment included fluid resuscitation, empiric antibiotics, and additional diagnostic testing. The EEG and MRI of the brain were relatively unremarkable. The patient and patient's family declined a lumbar puncture due to continued clinical improvement. Following observation care, no new issues arose and clinical improvement continued to be realized. The patient was deemed medically stable and discharged with a new prescription for acetaminophen as needed with a working diagnosis of post-concussive syndrome. 

The clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, hypoxemia, tachypnea that persisted despite observation care, acute renal failure, inability to maintain oral hydration, postresuscitation or a presenting Glasgow coma scale of less than 13, severe or persistent altered mental status despite appropriate treatment, worsening of neurologic function post presentation, new signs or symptoms (eg, vomiting, dizziness) that are severe or persist despite observation care, new focal signs on neurologic examination, new (or presumed new) intracranial pathology on imaging that requires intervention or monitoring beyond the observation time frame, cerebrospinal fluid (CSF) leak, recurrent seizures, evidence of increased intracranial pressure (eg, papilledema, bradycardia, or significant respiratory (eg, neurogenic pulmonary edema) or cardiac (eg, arrhythmia) abnormalities secondary to brain injury.[2][3]