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202103-136121

2021

Metroplus Health Plan

HMO

Trauma/ Injuries

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Lacerations (wound care)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. His medical and surgical histories were negative. He presented to an emergency room after playing with a knife while intoxicated.

The patient's vitals were temperature 97.1, pulse 86, blood pressure 129/92, respirations 19, oxygenation 98% room air. Physical examination demonstrated: "multiple lacerations involving the right upper extremity measuring 4x2.5 cm [centimeters] on the medial forearm and 2 cm [centimeters] on the lateral forearm with associated hematoma and superficial abrasion overlying the right eyebrow." All of the wounds were "superficial."

Serum laboratories demonstrated a normal hemoglobin of 12.9 and a normal lactate of 1.5. "CT [computed tomography] angiogram of the right upper extremity showed evidence of a forearm laceration with penetrating injury and possible injury to the cephalic vein at the laceration site. No arterial injury identified. No fracture or dislocation." Duplex ultrasonography of the right upper extremity "showed normal imaging."

The patient was admitted at an acute inpatient level-of-care with lacerations and alcohol intoxication. He received intravenous fluids, antibiotics, tetanus vaccination, and wound care. He was cleared by Psychiatry Consultation for discharge.

The patient was discharged home in good and stable condition with outpatient surgical follow-up and prescriptions for oral analgesics.

No, the Inpatient admission was not medically necessary.
The patient did not require admission at an acute inpatient level-of-care due to the following:

1) He did not have significant co-morbidities.
2) His vitals were stable.
3) He did not demonstrate on-going anemia.
4) He did not demonstrate significant blood loss; serum laboratories demonstrated a normal hemoglobin and normal lactate.
5) He did not have evidence of neurovascular injury.
6) He did not have evidence of orthopedic injury.
7) All of his injuries were "superficial."

All of the provided treatments (intravenous fluids, antibiotics, tetanus vaccination, wound care, Psychiatric evaluation) could have been provided at a lower level-of-care.

Based on his history, presentation, examination, and findings, the patient did not require admission at an acute inpatient level-of-care. All of the provided treatments could have been provided at an lower level-of-care.

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