Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischiorectal Abscess, Recurrent

Treatment admission for surgery

The insurer denied coverage for admission for surgery

The denial is upheld

According to the documentation submitted, this is an adult male with a history of hypertension and hyperlipidemia and an anal fissure that was treated in the past. The patient presented to the Emergency Room (ER) with complaints of rectal pain and bleeding. He was examined and admitted for care. 

According to Milliman Care Guideline (MCG) and based upon the clinical information provided, the patient could have had the abscess drained and been sent home without an acute care stay. As per the ER note the patient presented complaining of rectal pain and mild rectal bleeding that began in the morning. He denied constipation. His last bowel movement was that morning. He was afebrile with stable vital signs. On exam his abdomen was soft, non-tender with normal bowel sounds. Rectal exam revealed good tone with a 2x2 centimeter (cm) wound draining bloody, foul-smelling, purulent fluid. His white blood cell (WBC) count was 10.4. The assessment was rectal abscess, and the plan was computed tomography (CT) of the abdomen and nothing by mouth (NPO). The preop note indicated planned procedure of examination under anesthesia (EUA) and incision and drainage (I&D) of abscess. A CT of the abdomen revealed linear hyperattenuation within the left perianal subcutaneous fat with surrounding fat stranding, possibly reflecting an anal fissure with associated cellulitis. A single focus of gas was seen within the tract. As per the operative note the patient underwent EUA with partial fistulotomy and drainage of recurrent ischiorectal abscess and Seton placement under local anesthesia. Postoperatively, the patient did well; he was given a regular diet and pain medications and he was discharged to home with follow up.

As per the discharge summary the patient was status post anal fissure status post EUA and lateral sphincterotomy and was seen in his physician clinic for drainage from the perianal region; status post I&D of right perirectal abscess and insertion of mushroom catheter/perirectal abscess; he presented to the ER complaining of rectal pain and mild rectal bleeding. He denied constipation, fever, nausea, vomiting. He underwent EUA excision of fistula tract and Seton placement. He tolerated the procedure well, tolerated diet and was discharged to home on pain medication.

In summary, the patient had a perirectal abscess that was drained and he was sent home later that day. He did not have an elevated WBC and did not have a fever. He was stable and could have been kept on a 23-hour observation following the procedure, if necessary. The inpatient acute stay was therefore medically not necessary. 

This reviewer is knowledgeable in this condition and the recommended health care services and therefore, the medical necessity of the acute admission was not justified. 

The health care plan did act reasonably and with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for admission for surgery on the rectum is upheld. Medical necessity is not substantiated.