Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Fall.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented to the by ambulance after sustaining a fall hitting his head with reported loss of consciousness. The patient reported that his legs gave out and he fell down 25 stairs. The patient called 911. There were no corroborating witnesses. He reported back pain and chest pain. The patient has a history of polysubstance abuse and anemia.

The patient's vital signs were normal on arrival, and the patient was neurologically intact. The patient had staples on the back of his head from a recent laceration he sustained in an assault. Labs including hemoglobin were in the normal range. Drug screen was positive for methadone. The patient underwent CT (computed tomography) scanning from head to pelvis. CT (computed tomography) of the head, neck, face, and abdomen were negative for injury. CT (computed tomography) scan identified subtle fractures of the left 9th and 10th ribs, and chronic L2 (second lumbar spine vertebra) compression fracture. MRI (magnetic resonance imaging) was recommended to determine if the lumbar fractures were acute. The patient was to be NPO (nothing per oral) until the MRI (magnetic resonance imaging) was done. Internal Medicine consult was ordered for treatment of possible opioid withdrawal.

The patient was admitted to the acute inpatient level of care corresponding to his arrival in the Emergency Department before any lab studies, imaging or physical examination. Admission orders included intravenous Tylenol, Lovenox (anticoagulant), banana bag (given for alcohol / drug withdrawal), and Zofran (anti-emetic). Ativan was ordered as needed for withdrawal symptoms. Neurosurgical consultation was ordered as well as MRI (magnetic resonance imaging) of the thoracic and lumbar spines.

The following day, when transport came to pick up patient for MRI (magnetic resonance imaging), the patient was not in his room. His belonging bag was empty, his ID (identification) bracelet in the bed and his IV (intravenous) in the bed. It was determined the patient had left the hospital against medical advice.

Coverage of the acute inpatient admission denied by the health plan as not medically necessary. The hospital has appealed the denial of the acute inpatient level of care, which is the subject of this review.

The hospital, through its agent,  admitted the patient with acute rib and spine fractures. The care rendered according to agent could not have been done as an outpatient and the fact that the patient left against medical advice "underscores the importance of offering this clearly unreliable patient a change to obtain all of the needed follow-up immediately." They cite a Milliman guideline stating admission is indicated for a vertebral fracture requiring observation for instability or neurologic compromise due to the spine fracture.

No, the Inpatient admission was not medically necessary. The patient could have been cared for at a lower level of care.
The patient is a male that had reportedly fallen down a flight of stairs and lost consciousness. The patient called 911 after the incident and was brought to the emergency department.  The patient was admitted to acute inpatient level of care commensurate with his arrival at the hospital. On presentation, the patient had normal vital signs and normal mental status. The history was obtained from the patient. There was no corroborating witness. He reported back pain and chest pain. The patient has a history of polysubstance abuse and anemia. Vital signs were normal on arrival and the patient was neurologically intact. The patient had staples on the back of his head from a recent laceration he sustained in an assault. There was a previous history of the patient leaving the hospital against medical advice. Labs including hemoglobin were in the normal range. Drug screen was positive for methadone and the patient reported he was receiving methadone but did not have a card. The patient underwent CT (computed tomography) scanning from head to pelvis. CT (computed tomography) of the head, neck, face, and abdomen were negative for injury. CT (computed tomography) scan identified subtle fractures of the left 9th and 10th ribs, and chronic L2 (second lumbar spine vertebra) compression fracture. MRI (magnetic resonance imaging) was recommended to determine if the lumbar fractures were acute. The patient was to be NPO (nothing per oral) until the MRI (magnetic resonance imaging) was done. Admission orders included intravenous Tylenol, Lovenox (anticoagulant), banana bag (given for alcohol / drug withdrawal), and Zofran (anti-emetic). Ativan was ordered as needed for withdrawal symptoms. The next day before the MRI (magnetic resonance imaging) was done, the patient was found to have left the hospital without medical consultation.

The care the patient received would have been identical to that which he would have received at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.without compromise of the safety of the patient in the denial of the acute inpatient level of care.

The patient is a male with a self-reported history of trauma that presented to the medical center after reportedly falling down a flight of stairs with loss of consciousness. The patient called 911 on his own and was taken to the hospital by ambulance pursuant to paramedic evaluation after the 911 call. He had normal mental status and normal vital signs. Testing for drugs revealed presence of methadone. CT (computed tomography) from the head to pelvis only revealed subtle acute injuries to the 9th and 10th ribs. The compression fracture of the L2 (second lumbar spine vertebra) vertebrae was a chronic fracture. Neurosurgery recommended an MRI (magnetic resonance imaging) to further evaluate the spine. The patient was admitted pending the MRI (magnetic resonance imaging) but did not stay long enough to receive the study, leaving against medical advice. The information available at the time of admission did not warrant acute inpatient level of care. The patient could have been treated at a lower level of care without compromise to the quality of care rendered or patient safety. The care that this patient would have received at a lower level of care would have been identical to that which he in fact received without compromise of the quality of care rendered or patient safety.

In response to the hospital's appeal through its agent that inpatient level of care was required; the agent states the patient was admitted with acute rib fractures and spine fractures. In fact, the rib fractures were subtle and involved 2 lower ribs. Rib fractures normally do not require inpatient level of care. The treatment for rib fractures is pain medication. Regarding "spine fractures," the CT (computed tomography) did not identify any acute fracture. The compression fracture of L2 (second lumbar spine vertebra) based on the CT (computed tomography) was chronic in nature and not an acute injury. An MRI (magnetic resonance imaging) was recommended to insure there was no ligamentous injury. Inpatient care is not required while awaiting an MRI (magnetic resonance imaging).  The care rendered according to the agent could not have been done as an outpatient and the fact that the patient left against medical advice  "underscores the importance of offering this clearly unreliable patient a change to obtain all of the needed follow-up immediately." The agent states that the care could not have been done as an outpatient but provides no reason to back this conclusion or why observation level of care was not an option.

The agent cites a Milliman guideline stating admission is indicated for a vertebral fracture requiring observation for instability or neurologic compromise due to the spine fracture. In fact, the available evidence did not identify a spine fracture. There were no concerns of neurological compromise. MRI (magnetic resonance imaging) would have confirmed stability of the chronic fracture had it been done prior to the decision to admit.