Diagnosis: Motor vehicle accident
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

This patient presented to the emergency department (ED) following an accident in which he was a pedestrian reportedly struck by a car. He presented as a trauma patient to the ED. Vital signs identified elevated blood pressure and a heart rate of 107/minute. Glasgow coma score was 15/15. His evaluation included imaging with computed tomography (CT) scan of the head, cervical spine, chest, and abdomen/pelvis. These studies were normal. The patient was admitted for pain management. Overnight the patient received intravenous (IV) analgesia (Fentanyl). The following day the patient reported feeling better. Physical therapy evaluated the patient with the recommendation for use of crutches for ambulation. Diet was advanced and tolerated. He was considered to be stable for discharge the next day.

The submitted records do not support the medical necessity of inpatient admission for this patient.
This patient presented following an incident in which he was a pedestrian struck by a vehicle. There was no loss of consciousness at the scene of the injury, and he was awake, alert, and oriented with a Glasgow Coma Scale (GCS) of 15 at the time of hospital presentation. He had diffuse pain but was without identified injury based on the trauma work up. The patient was stable at the time of presentation and did not require surgical intervention. In this case the care and treatment provided could have safely been rendered with a lower level of care rather than an inpatient level of care. The lower level of care would allow for provision of IV fluid, IV pain medication, and overnight monitoring. The records support that this patient had an uncomplicated period. He remained hemodynamically stable without acute aberration of vital signs.
The patient was clinically stable and without acute injury at the time of ED presentation. He was monitored overnight and remained clinically stable with regard to vital signs. He was able to ambulate with crutches and tolerated a diet and was deemed clinically stable for discharge to his home. The care provided did not require an inpatient level of care and could have reasonably been rendered with a lower level of care.