Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wound infection (enterococcus faecalis)
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.  The denial has been upheld.

The proposed treatment is not medically necessary. 

The patient is a female with a history of asthma, coronary artery disorder (CAD), coronary artery bypass grafting (CABG) two times (X2), diabetes mellitus (DM2), hyperlipidemia (HLD), and anxiety.  The patient admitted for four days last year for non-reassuring fetal tracing, undergoing C-section with wound vac on within that time period. The patient's case was complicated postoperatively by hyperglycemia and medication management to improve hyperglycemia. 

The patient was instructed on the day of admission by her obstetrics office she should be admitted for intravenous antibiotics due to her wound culture results. 

The patient presented to the emergency room that day due to the above reason. The patient was noted to be afebrile on presentation and vitals showed the following: temperature (T) 36.9 Celsius (C), pulse (P) 76, respiratory rate 19, blood pressure (BP) 120/78, and pulse oximetry 97 percent. Labs on presentation showed white blood cell (WBC) count of 6.7, creatinine 0.89, platelet 214, and glucose 362.  Computed tomography (CT) scan of the abdomen and pelvis showed subincisional fluid and gas containing collection in the anterior pelvis, measuring approximately 1.7 by 11.2 by 1.9 centimeters.  There was diastases recti with protrusion of fat along the midline.  The patient underwent evaluation by an obstetrics and gynecology (OB/GYN) physician and the infectious disease physician. The patient underwent exploration of the collection and was noted to have drainage of the pus discharge from the collection. The patient was started on treatment with vancomycin, ceftriaxone and metronidazole with a plan of following up the culture collected in the emergency department.

Medical need is not established for inpatient hospital admission.

The patient presented to the emergency department for administration of intravenous antibiotics, but was afebrile on presentation and the patient had stable vital signs. Labs showed a normal white blood cell count. Labs on presentation showed white blood cell count 6.7, creatinine 0.89, platelet 214, and glucose 362.  Computed tomography scan showed collection, however evaluation by the treating physician and obstetrics and gynecology consultant did not identify the need for surgical drainage in the operating room for this collection. The patient was started on intravenous antibiotics and a plan was made to follow up the culture of the wound collected in the emergency room. 

The patient was clinically stable, without signs of sepsis on presentation and was able to tolerate oral intake and oral antibiotics. The patient was started on intravenous antibiotics on presentation, however the patient was clinically stable and there was no identifiable need for continued inpatient admission and stay. There was no immediate plan for further surgical drainage and the antibiotic choice was made appropriately after the infectious disease evaluation. 

The patient had been treated in the outpatient setting with antibiotics; however, the treatment was inappropriate, the patient needed to change to a more appropriate antibiotic regimen and the patient needed to continue treatment longer; however, the need for inpatient stay to achieve this is not established. The wound culture had grown streptococcus anginosus; the patient could have been managed at a lower level of care on intravenous antibiotics and then discharged on oral appropriate antibiotics as per the infectious disease recommendation with a plan to continue treatment for a longer duration.       

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