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

The patient is a female who presented to the emergency department (ED) following a fall from her booster seat to the floor, hitting her face. Afterwards, her right lower extremity was tender to touch. There was no loss of consciousness. Vital signs included heart rate 147, respiratory rate 30, temperature 37.2. Examination was significant for no acute distress, full range of motion in all extremities, good perfusion. X-rays were obtained, revealing a distal transverse femur fracture. Orthopedics and Trauma were consulted to assist with management. She was placed in a right leg cast. Child Protective Services was also consulted and responded to the call. Recommendations included Social Services consultation, so the child was admitted pending completion of the investigation. Skeletal survey was ordered, revealing no additional injuries. Injuries were consistent with the stated mechanism, so the child was deemed safe for discharge with the mother. Outpatient follow-up was arranged. The subject under review is the medical necessity for the inpatient hospital stay.

The health plan's determination is upheld.

An inpatient hospital stay was not medically necessary; the patient could have been safely managed at a lower level of care status.

Most long bone (femur and humerus) fractures in later infancy and early childhood are related to falls. Other potential causes include non-accidental trauma and bone fragility (e.g. [for example], rickets, vitamin D deficiency, osteogenesis imperfecta). In the case of non-accidental trauma, other findings may be present including retinal hemorrhages, skull fracture, intracranial hemorrhage, and rib fractures. Most fall accidents are related to being carried.

This infant was admitted for completion of a safety evaluation after sustaining a femur fracture following a fall. She demonstrated no other injuries, she remained hemodynamically stable, she was eating well, and pain was well controlled. While it was essential to guarantee safe discharge prior to releasing the infant with her mother, there was no need for acute inpatient hospital admission. She could have been safely managed at lower level of care.