Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscess. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld. 

According to the documentation submitted, this patient presented to emergency department (ED). As per the triage note, the patient had a fever associated with nausea and headache. She had colorectal surgery. As per the ED provider note, the patient has a history of colon cancer. She was seen in clinic and found to have induration around Pfannenstiel incision consistent with hematoma. She denied emesis. She was post-laparoscopic sigmoid colectomy, cystoscopy with stents and flexible sigmoidoscopy, and has had persistent diarrhea since discharge. She had a fever to 102.9 degrees Fahrenheit, headache and loss of appetite. She spoke to her surgeon who told her to come into the ED for further evaluation. As per the ED note, consideration was being given to possible bowel perforation, or post-operative infection, or post-operative complication, or urinary tract infection (UTI). In the ED she was afebrile with diffuse tenderness to palpation of the abdomen. There was no guarding or rebound. White blood cells (WBC) were elevated to 15.6. She was started on Vancomycin/Zosyn as well as ordered to have computed tomography (CT) of the abdomen with intravenous (IV) and rectal contrast. CT results showed a large subcutaneous abscess in left lower anterior abdominal wall with subcutaneous air. Per surgery the patient was to be admitted. Surgery did an incision and drainage (I and D) in the ED and found 100 cubic centimeters (cc) purulent material expressed. Wound culture was sent. Surgery also noted that CT did not show anastomotic leak and no obvious intrabdominal collection.

Surgery saw the patient and noted the patient was afebrile. Packing was changed in the wound. Zosyn was discontinued and oral Augmentin was started. 

Infectious Disease (ID) saw the patient and noted the wound infection as well as Clostridium difficile (C diff) positive. She was seen and found to be afebrile. The wound was open and clean with erythema noted. WBC was now 6.7. ID recommended oral (PO) Vancomycin for the C diff.

Progress notes showed the patient was afebrile in no acute distress. The plan was to continue Augmentin, and daily packing changes. Discharge planning was noted when okayed by ID with wound care at home. 

Vancomycin changed to PO for C diff positive and the patient was discharged. 

Milliman Care Guidelines (MCG) Health General Recovery Care 27th edition General Surgery or Procedure GRG: SG-GS (ISC GRG) notes that operative status criteria is ambulatory for many procedures. Examples include endoscopic procedures, embolization procedures, most biopsy procedures, many elective operations, including stoma repair, fistula repair, lymph node surgery, hernia repairs in the absence of ALL of the following: emergency procedure [e.g. ("for example") strangulated hernia], severe comorbid disease (e.g., severe infection), complex approach (e.g., morbid obesity, large chronic incarceration), hemorrhoid or rectal surgery, most breast procedures, percutaneous and dilation procedures, liver biopsy. In this case she should have been managed as an outpatient with a 23-hour observation without acute inpatient hospitalization as this is an ambulatory status and only required observation as she could have had the drainage of the abscess and placed on oral antibiotics and discharged without an acute inpatient admission. An I and D of the abscess should have been handled easily under observation care. The patient only required an I and D, antibiotics, and wound care - all of which could be done in an observation/ambulatory setting. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for a full hospital admission is not substantiated.