Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infected Breast Implant.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This patient is a female who underwent implant based breast reconstruction. She presented to the emergency department with purulent drainage from her reconstructed breast.  As per the patient, she noted slight erythema to the right surgical site, for which she was prescribed Augmentin. The patient then noticed purulent drainage from the Jackson-Pratt (JP) drain and was referred to the emergency department by her plastic surgeon. 

The patient has a medical history significant for bilateral mastectomy with implants and total abdominal hysterectomy (TAH), and hypertension (HTN). She had implant failure and required reconstruction. She was discharged with bilateral Jackson-Pratt drains. She noted flattening of the right breast with associated right shoulder/axillary discomfort. The Jackson-Pratt drain had increased output for 48 hours. 

Lab studies performed in the emergency department were remarkable for the following: glucose 133, white blood cell (WBC) count 11.2, and platelets 418. The patient was administered Unasyn three grams intravenously and Morphine four milligrams intravenously. There was concern for active infection at the site of implant, with Surgery recommending admission for further management/treatment with intravenous antibiotics.

The patient was treated with Unasyn three grams intravenously every six hours. Further lab studies revealed an improvement in leukocytosis, but persistent cloudy drainage to the Jackson-Pratt drain was noted.  Options were reviewed with the patient: continuing intravenous antibiotics versus operative washout with replacement of implant versus washout and removal. The decision was made to proceed with removal of implant. The patient was kept nothing by mouth (NPO) and proceeded to the operating room for removal of breast reconstruction pocket infection. The right breast implant and Alloderm were removed with purulent fluid noted. Washout of the breast cavity was performed with placement of new Jackson-Pratt drain. The patient tolerated the procedure well, with no complications noted. The patient was transferred to the recovery area in stable condition for further monitoring.  The patient's diet was advanced as tolerated and pain was adequately controlled with Oxycodone five/ten milligrams as needed. She was discharged.

No, the inpatient hospital admission was not medically necessary.
The notes document that the patent was receiving intravenous antibiotics but had minimal pain and was not septic. The patient and her surgeon decided the implant removal was the most appropriate treatment. She underwent implant removal. Her postoperative course was unremarkable. The patient could have been managed at a lower level of care because she was not acutely ill. 

Implant removal is generally an outpatient procedure.  According to MCG General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically it is 48-hours or less, but can be up to 72-hours in certain situations."  

This patient was treated with antibiotics and then underwent surgical implant removal. Implant removal is generally an outpatient procedure, and the records do not document a rationale for continued admission post implant removal. The patient could have been managed at a lower level of care because she was not acutely ill and was not septic.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The admission was not medically necessary.