Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Infection (cutaneous abscess).
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with a past medical history of arthritis, bipolar depression, bronchitis, chronic obstructive pulmonary disease (COPD), blood clots, presence of inferior vena cava (IVC) filter, and schizophrenia. The patient presented to the emergency room with complaints of swelling - abscess to the back of neck for nine months with purulent discharge. The patient did not have fever on presentation. The patient denied any headache, shortness of breath, chest pain and dizziness. The patient denied fever, nausea, vomiting, headache, or dizziness. In the emergency room, on presentation, the patient had normal vital signs and was afebrile: temperature was 97.8 Fahrenheit, blood pressure was 119/76, pulse was 84, respirations were 18, and pulse oximetry was 99% on room air. Examination showed neck swelling; the abscess size was 1.5 centimeters by 1.5 centimeters. The patient's lab results showed lactate 1.25, white blood cell (WBC) 10.1, and international normalized ratio (INR) 1.04. The patient was given intravenous Vancomycin and Levaquin in the emergency room. Incision and drainage were done for the abscess in the Emergency department by the surgery team who recommended the patient be followed up in the surgery clinic. The patient was admitted to inpatient hospital stay. The patient subsequently underwent computed tomography of the neck without contrast, and this also did not show soft tissue mass in the neck. The patient continued to improve and was stabilized and discharged.

The inpatient hospital admission was not medically necessary.

This patient presented with a swelling - an abscess that was present for nine months and had not failed outpatient antibiotics or other treatment before presentation. The patient did not have new symptoms or intractable pain that would require continued
management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered / work up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital. 
The patient was able to eat food, drink fluids and take oral medications. Although the patient had pain, it was not intractable, and not noted to be amenable to appropriate oral treatment. Care rendered during this time was of low intensity, routine nursing and physician monitoring. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates. In view of these findings and generally in accordance with Milliman Care Guidelines (MCG) therefore, the ongoing inpatient level of care for the above duration was not medically necessary.