Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain due to injury
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a male. He presented to hospital after sustaining an injury running into a slide on a playground. The child complained of pain in the left upper abdomen. 

The patient's physical examination showed a contusion in the left upper abdomen. The area was tender, and the patient guarded on physical examination. Focused abdominal sonography for trauma was negative for free fluid on two occasions. Due to persistent pain, a CT was ordered. Results were a 2.2 X 0.8 cm splenic laceration with intraparenchymal and subcapsular hematoma, and a small volume intraperitoneal blood in the upper abdomen. The injury was designated a Grade 2 (AAST [American Association for the Surgery of Trauma] classification) injury. 

The patient's initial hemoglobin level was 12.7 mg / dl. Follow-up hemoglobin after hydration was 11.2 mg / dl. The patient was admitted to the acute inpatient level of care commensurate with presentation to the ER and before the CT was done and before the decision to admit had been made. Admission orders written were for nothing by mouth (NPO), bedrest with bathroom privileges, and repeat blood count later that morning. 

The following morning the patient reported no abdominal pain. It was reported that the hemoglobin level had been stable for two consecutive draws, implying that the morning lab had been consistent with the previous lab, six hours prior. The patient was ordered for regular diet and activity as tolerated. The plan was to check a CBC (complete blood count) that evening and discharge if normal. The results of the follow-up CBC are not provided, but the patient was discharged.

The acute inpatient level of care was denied as not medically necessary. This review is subsequent to an appeal of the previous denial. 

The hospital, through its agent, has appealed citing Milliman Care Guideline Health General Recovery for Hematology with spleen trauma with blood loss or other need for acute (medical treatment). In support, the agent cites the drop in the child's hemoglobin level. 

The patient by both standard protocol (three days) and the shortened hospital stay under the ATOMAC protocol could have been treated at a lower level of care. The patient was only hospitalized for 18 hours from the time of the admission order and the total hospital time was less than 18 hours and total time in the hospital was just over 24 hours. The hospitalization in fact did not even include a post-midnight hospitalization if the period in the ER is not included. The care the patient would have been received at a lower level of care would have been identical to that which he received in fact without compromise of the patient's safety or the quality of care rendered.  The patient was hemodynamically stable throughout the hospitalization. The patient was pain-free, had stable hemoglobin, and was ordered for out of bed ambulatory, and regular diet. Hemoglobin was stable consistent with cessation of bleeding. The patient could have been safely discharged with sedentary precautions at home.

In response to the hospital's appeal, Milliman Care Guideline Health General Recovery for Hematology is cited with spleen trauma with blood loss or other need for acute (medical treatment). The guideline is generally indicated for adult patients with hematologic disease and not pediatric splenic trauma. In support, Nurse Anderson cites the drop in the child's hemoglobin level. The patient suffered an initial blood loss which was likely minor and commensurate with the IV hydration received. Subsequent hemoglobins were stable consistent with cessation of any bleeding related to the injury. 

The vast majority of pediatric splenic injuries can be treated nonoperatively without the need for splenectomy. Almost all Grade I and Grade II injuries are successfully treated non-operatively. Negative focused abdominal sonography for trauma is also a predictor of successful nonoperative management. 

The decision to admit was not made until after midnight with the admission order / bed request. Nevertheless, the admission was back-timed to the time the patient was triaged in the ED. The patient received a fluid bolus and continuous intravenous fluids beginning in the ER until the lab draw, which showed a hemoglobin of 11.2 mg / dl. This initial drop in hemoglobin over the initial six-hour period is often the result of hydration and not active bleeding. 

Guidelines for nonoperative treatment of splenic trauma are for admission based on the grade of injury plus one day. Newer protocols based on the ATOMAC (Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium) protocol, which was used here, base length of stay on hemodynamic stability and stable hemoglobin. The protocol calls for bedrest overnight with optional hemoglobin draws at 12 and 24 hours unless clinically indicated by vital signs. At 24 hours, the patient can safely be discharged home if hemoglobin stable, tolerating diet and minimal abdominal pain. All these criteria were met by the evening, which was the same day as the decision was made to admit. At the time of admission, and based on the CT findings and grade of the splenic injury, and protocols used by the institution, the patient could have been treated at a lower level of care with admission and discharge on the same calendar date.

Regarding another and more appropriate-Milliman Care Guideline for Abdominal Trauma, Blunt (S-05), goal for length of stay as ambulatory with expected brief (1-3 days) extension of stay for splenic trauma. The period of brief extension of stay would not preclude treatment at a lower level of care.