Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Biloma. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is male who has metastatic colon cancer. This patient was diagnosed with recurrent metastatic colon cancer to liver and lung, for which he is status post surgery for lung recurrence, x 6 cycles of FOLFIRI (Folic Acid, Fluorouracil, Irinotecan Hydrochloride) bevacizumab. CT (computed tomography) revealed 2 small cancer lesions into the liver. This was followed by ablation x 3 for recurrent segment VIII liver. 

Liver MR (magnetic resonance) revealed new lesion within the segment 8 ablation zone. Subsequently, this patient underwent central hepatectomy/ablation of tumor and was discharged home. 

Post-op the patient was seen and was complaining of back pain. He had labs and a scan. He presented to the hospital for admission with worsening upper back and shoulder pain. He had fever/chills for two days. Tmax (maximum temperature) was 100.8. In addition, the patient complained of pain with BMs (bowel movements) and inflammation around the rectum.

In summary, this patient has a metastatic colon cancer liver resection and cholecystectomy with resulting diagnosis of Biloma. This was drained by IR (interventional radiology). A perianal abscess was delayed in being diagnosed and treated. 

No, the Inpatient admission was not medically necessary. 

As per MCG (Milliman Care Guidelines) National Guidelines, this admission was not an example of safe, efficient, and effective medical care. The Expected LOS (Length of Stay) for percutaneous drainage procedure is Ambulatory Outpatient Care. 

After his liver surgery, postoperatvely, this patient was seen and complained of back pain, and he eventually had labs and a CT (computed tomography) scan. This patient presented to the hospital with worsening upper back and shoulder pain. This patient complained of fever/chills for two days. His Tmax (maximum temperature) was 100.8. Also, he complained of pain with BMs (bowel movements) and inflammation around the rectum, with his last BM (bowel movement) having been a day prior to admission. 

As per ED (emergency department care), the patient's temperature at Triage was 37.6 Celsius, with complaint of rectal pain possibly due to hemorrhoids. CT (computed tomography) revealed large fluid collection in the resection site (likely biloma). Leukocytosis was noted. There was concern for infected biloma status post recent liver resection. 

Treatment Plan included the following: Admit for expedited IR (interventional radiology) drainage; Empiric Zosyn. 

There is no well-stated medical documentation for if this patient needed expedited drainage of his biloma, why his was not performed on day of admission, and why it was not performed until the next day delaying efficient medical care. In addition, this patient was noted to have had rectal pain in the ED (emergency department). However, it was not until three days later when this patient was documented as having a left perianal phlegmon with cellulitis that a CT (computed tomography) pelvis was performed, which revealed new Left perirectal abscess for which incision and drainage was performed at beside. 

This patient likely should have had this Pelvis CT (computed tomography) with eventual drainage on that date as was eventually performed. 

In summary, in addition to this patient's two drainage procedures, Pain control, IV (intravenous) antibiotics, Sitz baths, and advancing diet all could have been provided safely, effectively, and efficiently at a lower level of care, with the patient being followed as ongoing Outpatient care either receiving ongoing IV (intravenous) antibiotics or changing to PO (oral) at the time of discharge. 

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

Based on MCG (Milliman Care Guidelines) National Guidelines, the Health Plan was trying to confirm that this patient received safe but at the same time efficient and effective medical care. Also, the Health Plan was trying to avoid unnecessary hospital days delays in providing overall health care to this patient.