201911-123247
2019
United Healthcare Plan of New York
HMO
Trauma/ Injuries
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Laceration
Inpatient Hospital
The patient is a male who fell over a bike and suffered a complex right groin laceration. He came in as a trauma activation, hemodynamically stable but with a deep and complex wound right groin. He had appropriate imaging and consults. He did not have vascular compromise; this was an isolated injury. He was appropriately taken to the operating room and the wound was interrogated and no major vascular injury was identified, his wound was washed out and complex wound repair was done. The patient did well and went home following day.
The health plan's determination is upheld.
As stated above, the patient was taken to the operating room and complex wound repair was done. The patient did well and went home following day. There was no intra-abdominal or retroperitoneal injury. There was no major blood loss, no limb threat, and no major vascular injury. This case did appropriately require resources, but ultimately did not require an inpatient stay. Given the isolated nature of this injury and low injury severity score, this complex wound does not meet inpatient criteria, based on Milliman Care Guidelines (MCG) for inpatient stay.
Given that no major vasculature was injured, and that the patient was always stable, this case does not meet inpatient criteria. The standard of care was to work up patient and as done in this case go to operating room to repair the wound laceration. This could have been accomplished at a lower level of care status, an inpatient status would not be medically necessary.