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

This is the case of a male who presented as a level II trauma after a motorcycle crash. The patient was helmeted and had no loss of consciousness. After a thorough workup, his injuries consisted of a friction burn to the face and bilateral upper extremities and a scaphoid fracture. He was admitted with consultations from orthopedic surgery and trauma surgery. The scaphoid fracture was managed non-operatively and the patient was observed for possible internal injuries given the mechanism of his crash. He improved and was discharged. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

An inpatient stay was not medically necessary for this patient. This patient had some abrasions of the face and upper extremities, as well as a scaphoid fracture. He required no inpatient surgery. The patient had no hemodynamic instability and did not have any interventions that required inpatient treatment. While a period of monitoring for possible internal injuries would be appropriate, a full inpatient admission is not warranted. The computed tomography (CT) scans were thorough and have a sensitivity for blunt abdominal trauma of at least 95%. It is more than appropriate to admit at a lower level of care status.