Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wound Dehiscence
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for hyperlipidemia, hypertension, obesity, Herpes genitalis, lichen sclerosis with cancer of right vulva status/post (s/p) right hemi-vulvectomy and right medial thigh VY flap which was complicated by wound dehiscence. She presented to the emergency department (ED) with complaints of copious exudate drainage and pain on the right leg skin graft site that had been debrided. Her outpatient treatment course had been complicated by some cellulitis around the VY flap that had some dry necrosis of distal flap. She had been taking Cipro/Doxycycline in outpatient setting. She reported needing adjuvant chemotherapy and radiation therapy per gynecologic oncology. Vital signs in the ED were a blood pressure (BP) of 145/72, pulse 83, respiratory rate (RR) 20, temperature 97.9 degrees Fahrenheit, peripheral capillary oxygen saturation (SpO2) 98%, and weight 93 kilograms (kg). The physical exam was notable for right (R) medial thigh with large open wound with fibrinous tissue at base, mild surrounding erythema, scant serous fluid.
The patient was admitted to the plastic surgery service for operating room (OR) debridement, washout and wound vacuum-assisted closure (VAC) placement s/p failed outpatient management. She was maintained nothing by mouth (NPO) and  was taken to the OR where debridement of subcutaneous tissue, including epidermis and dermis of the open wound of the right thigh was performed under general anesthesia without complications. Postoperatively she was instructed on local wound care with Bacitracin/Xeroform/dry gauze dressing. She was provided with prescriptions for antibiotics, pain medication and stool softeners with dressing change supplies. She was medically cleared for discharge with continued follow up care in the outpatient plastic surgery clinic. At issue is the medical necessity of an inpatient stay.
 Inpatient admission was not medically necessary for this patient. The patient underwent debridement of her right necrotic V-Y flap. She was physiologically stable prior to and after the debridement and washout procedure. The procedure was uncomplicated, and she was discharged on the day of the procedure after recovery. She did not have any clinical issues that required acute inpatient care. Flap debridement, wound washout and placement of wound VAC are outpatient procedures in this case. According to the Milliman Care Guidelines, 24th Edition, "General Admission Criteria", Admission is indicated for 1 or more of the following:
-Hemodynamic instability
-Hypertension requiring inpatient treatment
-Acute cardiac or peripheral ischemia
-Cardiac arrhythmias of immediate concern
-Severe heart failure
-Respiratory abnormalities
-Severe airflow or ventilation abnormalities
-Impending or actual respiratory arrest
-Neurologic abnormalities
-New-onset severe neurologic findings
-Suspected acute intra-abdominal process
-Severe physiologic disorder
-Abdominal abnormalities
-Acute renal failure
-Significant uremic complications
-High fever or other high-risk infection situation
-Temperature less than 90 degrees Fahrenheit  (32.2 degrees Celsius) (rectal)
-Severe nutritional abnormalities
-Severe electrolyte abnormalities
-Acute blood loss causing significant abnormality
-Severe anemia
-High-risk low platelet count
-Disseminated intravascular coagulation
-Severe adverse drug or systemic toxin reaction requiring inpatient treatment
-Severe pain requiring acute inpatient management
-Severe behavioral health issues
-Inpatient monitoring needed; examples include:
-Vital signs, neurologic signs, or vascular checks more frequently than every 4 hours
-Cardiac or respiratory monitoring beyond the scope (eg, over 24 hours) of observation care
-Pulmonary artery catheter monitoring
-Suspected compartment syndrome
-Cerebral bleeding, hydrocephalus, or vasospasm monitoring
-Increased intracranial pressure or cerebral edema monitoring
-Fetal monitoring
-Treatment requiring inpatient care; examples include:
-IV fluid to replace significant ongoing losses (greater than 3 liters per square 
 meter [ L/m2] per day)
-High concentration oxygen (greater than 40%)
-Frequent respiratory therapy (more frequently than every 4 hours) to maintain airflow rates greater than 60% of baseline
-Epidural analgesia(83)
-IV anticoagulation, vasoactive, or antiarrhythmic medication
-Acute thrombolytics (generally require 24 hours of observation)
-Emergency procedures needed.
This patient did not have any of these conditions. She was stable prior to and after a procedure that is generally performed as an outpatient. She could have been managed at a lower level of care.