Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Buttock Abscesses
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient is a female who presented to the Emergency Department (ED) for evaluation of multiple left buttock abscesses that she had for a week associated with swelling, tenderness, fevers, and chills. The patient stated that they started about 1 week ago and had increased in size. The patient endorsed feeling feverish and sweaty which improved with Tylenol, but she did not measure her temperature at home. She denied any history of frequent abscesses; and reported only one previous abscess last year. She was afebrile with stable vital signs. Exam revealed left buttock with six discrete small abscess two fluctuant, and the rest with induration. None had active purulent discharge. There was tenderness to palpation of the lesions. There was no rectal extension as all were on the buttocks. The assessment was multiple abscesses to the left buttock and the plan was intravenous (IV) antibiotics, labs and surgery consult. White blood cell (WBC) count was 12.6. Surgery saw the patient and noted that incision and drainage (I & D) was to be done.

As per General Surgery History and Physical, the patient complained of pain in her left buttock for 1 week. She reported having fevers, and chills. She had a pimple on her buttock that progressed 1 week ago and resolved according to the patient but now came back. She was afebrile with a WBC of 12.6. There was fluctuance at 4 different sites without purulence noted. The plan was to admit to surgery, regular diet and drain the abscess at the bedside. She underwent I & D of the left buttock and left posterior lateral thigh abscess. She did well and was discharged to home with follow up with the clinic.

According to according to MCG (Milliman Care Guidelines) health General Recovery Guidelines 25th edition General Surgery or Procedure, 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. strangulated hernia), Severe co morbid 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 could have been managed as an outpatient without acute inpatient hospitalization as she could have had the drainage of the abscess and placed on oral antibiotics and discharged without an acute inpatient admission. An I & D of the abscess could have been handled under observation care. 

The patient had several buttock abscesses which were drained at the bedside. She was afebrile and had a WBC of 12.6 on admission. She was sent home the day after I & D of the abscesses. This should have been done as an observation status and did not require an acute inpatient admission. The insurer is correct in denying the hospital admission as the patient did not meet the criteria for acute admission. She was stable and could have been observed and discharged without an acute admission stay.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

Therefore, based upon the clinical information provided, the inpatient admission was not justified at the acute level as the patient could have been treated as an outpatient/observation status. 

The insurer's denial of coverage for the inpatient hospital is upheld. Medical Necessity is not substantiated.