Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma
Treatment: Full Hospital Admission
The insurer denied coverage for full hospital admission.
The denial is modified.

This is the case of an adult male who presented to the emergency department (ED) as a level 2 trauma activation. The patient reported multiple areas of pain but worse in his left knee and right shoulder. X-rays of right shoulder, humerus, left hip, femur and knee, left ankle, left tibia and fibula and right ankle were all reviewed and did not show evidence of fracture or dislocation. The assessment was right shoulder and left knee contusion with right hip/knee contusion with multiple abrasions after a motorcycle crash the previous night. The recommendations were pain control and X-rays to right hip, femur, knee as well as physical therapy (PT).

Physical medicine saw the patient and noted right knee tibial plateau fracture and left knee Anterior Cruciate Ligament (ACL) rupture with extensive posterolateral corner and lateral collateral ligament injuries. Computerized tomography (CT) of the chest was negative. CT of thoracic spine and lumbar spine was negative. X-rays of left hip/femur/knee/tibia/fibula/ankle were negative. X-ray of the right shoulder/humerus/elbow/forearm /wrist were negative. The hospital course was complicated by uncontrolled pain and difficulty with weight bearing.

Magnetic Resonance Imaging (MRI) of the right knee showed depressed fracture of the anterior aspect of the tibial plateau and MRI of the left knee showed ACL rupture. PT noted as per the team the patient is not weight bearing of bilateral lower extremities. The physical medicine and rehabilitation service was consulted for physiatrist co-management and assistance with disposition planning. Since admission, the patient has been participating in a bedside program. The plan was pain control and bedside therapy to continue. They noted that the patient would benefit from inpatient rehab to maximize his functional recovery, acute versus subacute rehab pending further workup.
	
Finally, according to Milliman Care Guidelines (MCG) health General Recovery Care 26th Edition General Admission Criteria admission is indicated for 1 or more of the following: Hemodynamic instability; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern;  severe Respiratory findings; Severe airflow or ventilation abnormalities; severe heart failure;  Impending or actual respiratory arrest; Neurologic abnormalities; New-onset severe neurologic findings;  Suspected acute intra-abdominal process; Severe physiologic disorder; Abdominal abnormalities; Acute kidney injury (stage 2); acute renal failure (stage 3 acute kidney injury); Significant uremic complications; High fever or other high-risk infection situation; Temperature less than 95 degrees Fahrenheit (F) (35 degrees C [Celsius]) (rectal); severe electrolyte abnormalities requiring inpatient care; Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; Severe adverse drug or systemic toxin reaction requiring inpatient treatment; Severe pain requiring acute inpatient management; Severe malnutrition; Severe behavioral health issues; Inpatient monitoring needed; Treatment requiring inpatient care; Emergency procedures needed. 

This patient did have the indications for admission based upon the above criteria. This patient required inpatient treatment as surgery was being considered. But once it was determined that surgery would be done as an outpatient and all the studies were done, the patient should have been placed on an alternate level of care and not acute inpatient care as he required PT and in acute care rehab setting not in an acute inpatient hospital.

The insurer's denial of coverage for the full hospital admission is partially substantiated.

The health plan acted partially reasonably with sound medical judgment in the best interest of the patient.

The initial inpatient admission for five days was medically necessary for this patient to determine extent of injuries, for pain control and definitive planning. However, as of the remaining/latter five days, the patient did not need further acute inpatient care and could have been kept on an alternate level of care until a rehabilitation center was found. 

The health plan acted partially reasonably with sound medical judgment in the best interest of the patient.