Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bone Fracture/Break
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Upheld

The patient is a female with osteoarthritis, diabetes, cranes, hypertension, and polysubstance use with alcohol, who presented to the emergency department (ED) after a fall. She reported no loss of consciousness and reported drinking alcohol. She was diagnosed with a left wrist fracture and cerebral vertebrae 1 (C1) transverse process fracture. An orthopedic consultation note documented that the patient presented with left hand pain and swelling with deformity after a fall. X-rays in the emergency department showed a displaced fracture of the left distal radius and ulna. On exam there was a gross deformity of the left wrist with swelling and ecchymosis as well as tenderness and a cervical collar in place. There was intact sensation, pulses, and strength. The provider stated that hematoma block was performed of the left wrist with lidocaine, and a reduction was performed. The left upper extremity was placed in a sugar tong splint. Post-reduction x-rays were obtained and showed some residual displacement. The provider stated that the patient may require surgery. There was a plan for the trauma service to admit the patient.
A neurosurgery note the following day documented that the patient had a C1 right transverse process fracture after falling down 14 stairs. The patient denied neck pain. She stated that she had stiffness while wearing the cervical collar. She denied numbness or tingling. On exam, she had mild tenderness of the right side of the neck, no pain with cervical motion, a cervical collar in place, and full strength in the upper extremities. The provider recommended magnetic resonance imaging (MRI) to further evaluate the fracture. An orthopedic progress note documented that the patient reported mild left wrist pain. The left upper extremity was in a splint, and there was moderate swelling of the fingers. There was no need for acute surgical intervention. They recommended continued splinting, elevation, Tylenol, and a follow-up in orthopedics outpatient in one week for an x-ray. The patient was stable for discharge from an orthopedic standpoint. The patient denied any acute events. She reported soreness over the arm and back, which had not worsened. She was pending the MRI. She was hemodynamically stable.
After that, the patient was noted to have no acute events, only left arm pain, and she was ambulating without assistance. She had a cervical collar in place. She was noted to have adequate pain control and was hemodynamically stable. The MRI of the cervical spine was recommended prior to clearing the cervical collar. The MRI documented a nondisplaced fracture of the right C1 transverse process and inferior margin of the right occipital condyle. Neurosurgery recommended discharge with a cervical collar and outpatient follow-up.
At issue is the medical necessity of the inpatient stay.
The health plan's determination of medical necessity is upheld in whole.
The requested inpatient stay was not medically necessary. In this circumstance, the patient presented after a fall and was found to have a displaced left distal radius and ulna fracture and nondisplaced C1 transverse process fracture upon presentation to emergency department. She underwent a reduction of the left wrist under hematoma block and was splinted. She was hemodynamically stable and had no acute neurologic deficits. She had no significant comorbid conditions. Orthopedics recommended outpatient follow-up. Neurosurgery recommended MRI to determine the necessity of the cervical collar. The MRI was equivocal, and the provider recommended discharge with a cervical collar and plan for outpatient follow-up. She was noted to be hemodynamically stable and had no acute neurologic deficits or significant comorbid conditions that required skilled care at an inpatient level.