Diagnosis: Facial Laceration.
Treatment: Emergency Department Visit.
The insurer denied: Emergency Department Visit.
The denial is overturned.

The patient is an adult male who was seen in the emergency department. The patient was assaulted, sustaining a three-centimeter (cm) laceration to his left cheek. There was no evidence of fracture. A plastic surgeon was consulted to repair the wound. The wound was closed by the plastic surgeon while the patient was in the emergency department (ED). Following the patient's emergency department evaluation, he was discharged home. The patient's health plan has denied coverage for this emergency department evaluation on the grounds that the plan criteria for medical necessity have not been demonstrated. Specifically, it is written that insufficient records were received to establish medical necessity. The patient has appealed this denial.

The proposed treatment (emergency department visit) was medically necessary.

The patient presented to the emergency department with a complex facial laceration. A plastic surgeon was consulted. The plastic surgeon repaired the patient's facial laceration in multiple layers. Debridement of devitalized tissue was required. There is no lower level of care that could have accomplished this complex surgical procedure. This health plan states that for a service to be medically necessary it must be clinically appropriate in terms of site and considered effective for the patient's Illness, injury or disease. A hospital emergency department evaluation was clinically appropriate for this patient. He had a complex facial laceration that required repair by a plastic surgeon. There was no other site of care that could have provided the medical treatment that this patient required.