Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hidradenitis Suppurativa
Treatment Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is the case of a patient with a past medical history of hidradenitis suppurativa who was referred by her doctor through the emergency department for preop lab and admission testing due to Hidradenitis suppurativa flair. The patient walked into the ED (emergency department) and was admitted with the chief complaint of here for surgery for hidradenitis suppurativa. As per the ED provider note, the patient presented to the ED with chief complaint of groin wounds. The patient stated her surgeon referred her to the ED for admission to the hospital with plan to consult surgery. The patient stated she was feeling well. She denied fever, chills. On exam, she was afebrile and appeared nontoxic. The plan was to do labs for preop (pre-operative) and admission testing. Labs revealed a WBC (white blood cells) count of 10.2.

The patient was taken to the operating room. As per the operative note, the patient underwent excision of right and left inguinal hidradenitis and excision of left buttock hidradenitis suppurativa. Path revealed 5 x 3 x 0.1 cm (centimeters) for bilateral inguinal hidradenitis. Another piece of skin which was 2.2 x 1 x 0.5 and 3 x 2.2 x 1.5 cm was submitted from the buttocks. The patient received wound care and pain medications and was discharged home with a referral to home care services.  As per the discharge summary, the patient underwent bilateral hidradenitis suppurativa of the groins and buttocks. She was started on antibiotics and underwent procedure without complications.

Based upon the information provided, the inpatient admission was not medically necessary as the patient should have been treated in an ambulatory/observation setting as noted by the insurer. The patient presented to the ED as told to her by her physician and did not have the surgery until later. She then stayed in the hospital without any clear reason for this except to monitor the wounds which were closed with staples. She could have been treated, if necessary, on oral antibiotics and discharge after a 23-hour observation with outpatient follow up.
According to the guidelines of MCG (Milliman Care Guidelines) General Recovery Care- 26th edition Wound and skin management Surgery or other care covered by this guideline is indicated for 1 or more of the following: Skin lesion excision or other surgery needed, as indicated by 1 or more of the following: Melanoma; Other malignant tumor (e.g., basal or squamous cell carcinoma); Benign lesion that is causing significant functional impairment; Benign tumor with recurrent infection not responsive to nonsurgical therapy; Severe hidradenitis suppurativa with tracts or abscesses; Most incision and drainage of skin or tissue; Most elective skin grafting; Partial- thickness burn care for less than 10% of body surface area if not involving hands, feet, face, perineum, genitalia, or major joints. It is Inpatient: for other surgeries and procedures, inpatient stay will usually be needed because of 1 or more of the following: Inpatient procedure or Wound and Skin Procedures and Care AND 1 or more general admission criteria. In this case the surgery was uneventful, and the wounds were closed primarily and therefore there was no indication for prolonged hospital care and for general admission criteria but rather observation.

Therefore, based upon the clinical information provided, the inpatient admission was not justified and should be denied as there was no indication that inpatient care was needed in the chart. The insurer is correct in denying this admission. 

Based upon these findings, 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 the inpatient admission is upheld. Medical Necessity is not substantiated.