Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infected Mastitis

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned.   

This is a female patient who presented to the Emergency Department (ED) with complaints of bilateral breast pain worse on the left, and associated with fever; up to 103 for several days.  The patient reported that she had recently given birth. The patient was prescribed dicloxacillin by her obstetrician/gynecologist however; the erythema continued to worsen.  On examination the patient bilateral breasts were enlarged.  Left breast was tender to palpation with diffuse erythema.  No nipple discharge was noted.  Slight erythema was noted on the right.  She was afebrile but white blood cell (WBCs) counts were elevated at 12.4.  She was consulted by General Surgery and Infectious Disease.  It was suggested that the patient be admitted for intravenous clindamycin and a breast ultrasound to rule out abscess.  The patient was admitted and infectious disease was also consulted while admitted.  The patient was discharged with instructions to follow up with her primary care physician.

The diagnosis of infective mastitis is based on clinical manifestations.  Culture of the breast milk can be useful to guide selection of antibiotics; it is particularly important in the setting of infection that is severe, hospital acquired, or unresponsive to initial antibiotics.  Imaging is useful if lactational mastitis does not respond within 48 to 72 hours to supportive care and antibiotics.

Most episodes of lactational mastitis are caused by Staphylococcus aureus.  Methicillin-resistant S. aureus (MRSA) has become an important pathogen in cases of lactational mastitis.  Initial management of non-severe lactational mastitis consists of symptomatic treatment to reduce pain and swelling (nonsteroidal inflammatory agents, cold compresses) and complete emptying of the breast (via ongoing breastfeeding, pumping, and/or hand expression).  Management of infective lactational mastitis (lactational mastitis with persistent symptoms beyond 12 to 24 hours, with fever) consists of the above measures in addition to administration of antibiotic therapy with activity against S. aureus. 

In the setting of severe infection (eg, hemodynamic instability, progressive erythema on antibiotics), empiric inpatient therapy with vancomycin (15 to 20 mg/kg/dose every 8 to 12 hours, not to exceed 2 g per dose) should be initiated; therapy should be tailored to culture and sensitivity results.

The optimal length of therapy is not certain; 10 to 14 days may reduce the risk of relapse, but shorter courses (5 to 7 days) can be used if the response to therapy is rapid and complete.  In patients with severe mastitis or abscess, once there are signs of clinical improvement with no evidence of systemic toxicity, antibiotics may be transitioned from parenteral to oral therapy.

This patient had progressive erythema on antibiotics (oral dicloxacillin), so based on the above, inpatient management for IV antibiotics was medically necessary.  Once the cultures of the breast milk came back and the patient was transitioned to oral Bactrim therapy, she was discharged home.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for inpatient stay is overturned.  The medical necessity is substantiated.