Diagnosis: Assault by sharp object

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of a male with a history of stab wound and thoracotomy. The patient presented to the emergency department (ED) with complaints of chest pain. He was a self-referral. He was stabbed and had a chest tube placed and still had staples in his chest and was now having a lot of pain. As per the provider note, the patient stated that he was stabbed three times on his left side. He had the chest tube removed 5 days ago. The pain is 10/10 along the left sided rib cage. He denies any new trauma or fall. He denied any bleeding from the incision. The patient suffered stab wounds to the abdomen and chest. He was discharged. He reported that the oral medications he was discharged with did not help with the pain and now he is out of those, and the pain is even worse. He denied any fever or chills. He stated he spoke to the surgeon who performed the operation who told him to come to the ED. He was afebrile with stable vital signs. On exam he appeared to be in no acute distress. His breath sounds were normal. He had a well healed thoracotomy incision with staples in place without erythema or drainage. The plan was labs, intravenous (IV) pain control, chest x-ray (CXR) and surgery consult. On hand off, the pain control improved. His hemoglobin (Hgb) was 6.9 and the plan was to transfuse one unit and they will see him this morning.

The patient was ambulating and tolerating diet. The pain was well controlled with intervention by pain management.

According to MCG (Milliman care guidelines) Health Inpatient and Surgical care 25th Edition: Chest pain ORG: M-89 (ISC) this patient could have been easily managed in an alternative setting without an acute inpatient admission as he did not have any acute serious injury now.

Furthermore, MCG Health General Recovery care 25th Edition: Pain management hospital, this patient could have been treated for pain management as it was more than 7 days since his discharge with outpatient management for his pain control. He did not need an acute admission for this or for a blood transfusion for his hematocrit (Hct) of 21. All he needed as noted by the insurer was observation with pain management.

Based upon the information provided, the hospital inpatient admission is denied as the patient should have been treated on an observation status without an acute inpatient admission. This patient presented due to pain and did have anemia which could have been easily managed without an acute inpatient admission.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.