Diagnosis: Concussion
Treatment: Inpatient admission
The insurer is denied coverage for the inpatient admission.
The denial is upheld.

This is a male patient with a history of hypertension and hyperlipidemia. The patient presented to the Emergency Department (ED) after sustaining a fall off of a six step ladder. He reported not hitting his head as per his ring video. His presenting complaints were right arm and right shoulder pain, and a right elbow laceration. The patient's wife reported that the patient was acting confused; the patient denied a loss of consciousness. The x-ray was negative for fracture. The right elbow laceration was repaired by the Emergency Department. The patient was admitted for observation given the symptoms of a likely concussion. A computed tomography (CT) of the head was done that showed a slight periventricular white matter chronic ischemic type change, ventricular prominence, and cortical atrophy. There was no evidence of acute intracranial hemorrhage or an acute appearing territorial infarction. The patient was stabilized and subsequently discharged.

The inpatient admission was not medically necessary. The patient presented to the hospital after a fall from a ladder. Documentation indicates that a video of the incident did not show him hitting his head. Following the fall, the patient had right-sided pain and confusion. A CT scan of the head did not show any acute process. The patient was diagnosed with a possible concussion despite no evidence of head trauma or hitting his head on the video capture. He was observed in the hospital overnight with resolution of his symptoms and then discharged home the next day. None of the care provided required an acute inpatient admission. The patient did not have an injury that required inpatient care. The neurologic complaints of confusion did not warrant acute inpatient care. There was no neurologic deficit such as aphasia, weakness, or inability to ambulate. There were no significant laboratory abnormalities. There were no significant EKG abnormalities. There were no significant imaging abnormalities. The patient did not require acute nursing services. The patient did not require rehabilitation on discharge. All of the care provided could have been performed at a lower level of care.

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

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.