Appeal type: Medical necessity
Decision: Upheld

The patient is a female with medical history significant for late premature birth at 36-1/7-weeks' gestation, speech delay, and failure to thrive status post gastrostomy tube placement that presented to the emergency department (ED) for evaluation of worsening scalp hematoma six days after an unwitnessed fall.  She had been playing with siblings and fell backwards hitting the posterior part of her head at the border of carpet and wood flooring.  There was no loss of consciousness, and she cried immediately.  She had no vomiting or alteration in alertness.  She initially had a small bump on the right side of her head.  Two days later, because the bump was getting larger, she was taken to the ED for evaluation.

She had no changes in mental status, activity level, or appetite.  Computed tomography (CT) was done at that time and was read as negative.  Her neurologic examination was unremarkable, so she was discharged home.  Late on the same day, her father noticed that the swelling had become bilateral and larger, so he took her back to the ED.  That day, she had some low-grade fever, nasal congestion, and one episode of vomiting following a gastrostomy tube (GT) feeding.  Vital signs included temperature 99.2, heart rate 147, respiratory rate 22, and blood pressure 88/66.  Examination was significant for no acute distress, boggy soft hematoma in the occipital region extending onto the superior aspect of the scalp increased in size from previous visit, moist oral mucosa, clear lungs, and non-focal neurologic exam.  Laboratory evaluation revealed anemia with hemoglobin 8.7, mild metabolic acidosis with carbon dioxide (CO2) 21, and normal coagulation screening. The CT from the previous visit was re-evaluated and there was suspicion of a linear skull fracture.  Neurosurgery was consulted, with recommendations for follow-up hemoglobin and if stable, discharge home with follow-up in six weeks.  She was admitted overnight with diagnosis of subgaleal hematoma and linear skull fracture, for neuro checks every four hours and repeat complete blood count (CBC) in the morning.  She remained stable overnight, with repeat hemoglobin 8.0.  She was deemed stable for discharge home to follow-up with the pediatrician in two days and neurosurgery in six weeks.  The health plan's determination is upheld.

Findings consistent with high risk of intracranial injury include depressed level of consciousness not clearly due to alcohol, drugs, metabolic abnormalities, or postictal; focal neurological findings; decreasing level of consciousness; and penetrating skull injury or depressed fracture.  Patients in the low-risk group may not need a CT scan.  They may meet criteria (not included here) for monitoring at home.  Patients in the moderate risk group will most likely need a CT scan, and occasionally may also require skull x-rays.  These patients may also qualify for home observation, but only if their only moderate risk factor is loss of consciousness.  Those in the high-risk category require hospitalization, CT scan, and may need surgery.  In general, patients with occipital fractures are at higher risk for intracranial injury.

This patient would fall into a moderate risk category based on her presentation to the ED the second time.  She had significant subgaleal swelling, the fall was unwitnessed, and she had suspected skull fracture (non-depressed) on CT scan.  It was not unreasonable to monitor her overnight given the significant increase in size of the hematoma, including serial neuro checks and hemoglobin levels.  However, she was overall stable, with no alteration in consciousness, no vomiting, and no evidence of hemodynamic instability.  She did not require acute inpatient stay and could have been safely managed at a lower level of care status.