Diagnosis: Trauma/Injuries.
Treatment: Inpatient Hospital.
The insurer denied the inpatient stay.
The denial is upheld in whole.

The patient is a male who presented to the emergency department with head trauma and amnesia. Reportedly, the patient was assaulted outside a bar 2 days prior. According to the history and physical (H&P) note, after the assault the patient was functioning well, however he experienced a headache. He worked the day before without issues. Reportedly, the patient underwent a computed tomography (CT) scan of the head that demonstrated right epidural hematoma.
When the patient was seen by the admitting physician, he was hemodynamically stable. He was awake, alert, and oriented times 3. The patient was speaking clearly and had normal bilateral breath sounds. His blood pressure was 130/90, heart rate 70 beats per minute. The Glasgow Coma Scale was 15. The patient had ecchymosis around the left eye as well as small healing abrasion in the right occipital area. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed sodium 140, potassium 4.5, chloride 104, bicarbonate 24, blood urea nitrogen (BUN) 21, creatinine 0.97, glucose 88. White blood cell count was 5.4, hemoglobin was 14.8, hematocrit was 41.8, and platelets were 280.
The patient was admitted to the hospital with a right epidural hematoma and right frontal skull fracture.
The patient was evaluated by a neurosurgeon who indicated in the consultation note that no acute neurosurgical intervention was required. The patient was recommended to have a CT scan of the head to monitor the expansion of hematoma. The patient also required monitoring for acute changes in his mental status.
The patient was admitted to the hospital and subsequently transferred to the intensive care unit with questionable worsening of an epidural hematoma on the repeat CT scan of the head.
In the intensive care unit, the patient was monitored closely, including frequent neuro checks.
While in the intensive care unit, the patient remained in stable clinical condition and had no issues overnight. On the next day after the day of admission, the patient had a minimal headache. The patient tolerated his diet and ambulated without difficulties.
Therefore, he was discharged from the hospital the next day after the day of admission.

The health plan's determination is upheld.

The hospital admission was not medically necessary for this patient at the acute inpatient level of care. Even though the patient was admitted to the intensive care unit, he remained in stable clinical condition with significant improvement in his symptoms within a short period of time. Furthermore, the patient did not require any diagnostic studies, procedures, or surgical interventions necessitating admission at the acute inpatient level of care. The review of medical records demonstrated that the severity of the patient's condition and the complexity of the services provided were most appropriate for a lower level of care status.