Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a gravida (G) 2 para (P) 1 011 female who presented on postoperative day #8 status post prior low-transverse cesarean delivery. She was sent from the doctor's office due to surgical site infection and superficial wound separation with drainage.

The patient reported no abdominal swelling, chills, or nausea. Her current medications including oxycodone for pain and ibuprofen for pain with a prenatal vitamin. Her review of systems was normal except as the exceptions above. The patient's temperature presentation was 100.8 Fahrenheit (F) with a heart rate of 114, and respiratory rate of 18. Blood pressure was normal at 131/93. Her height was 5 foot 4 inches. Her examination noted cellulitis of the incision that was 2 centimeter (cm) in the midline with an opening in the incision site with drainage of purulent pink fluid with an additional 5 millimeter (mm) opening in the right lateral aspect. A Q-tip was inserted to assess the depth of the wound separation and the fascia was noted to be intact. It was erythema along the edge of the incision about 3-4 cm superior border extending to the bilateral inguinal creases and down to the mons pubis. There was induration along the inferior border of incision of 1-2 cm.

The patient was seen by infectious disease who had no other recommendations in this case. On hospital day 1 the patient had no other complaints. She was on Keflex 500 mg every 6 hours and clindamycin 300 mg every 6 hours with probiotics upon discharge for a plan of 2 weeks of antimicrobial therapy. As discussed with the OB/GYN resident, the patient and her family, the patient was to follow-up in the outpatient clinic. Her diagnosis was sepsis due to a postop wound infection with superficial abscess draining. The patient had postoperative cellulitis of the surgical wound. She was discharged to home with follow-up scheduled. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

In this case, the patient was noted to have a wound infection and separation. There was no evidence of sepsis and no evidence of unstable vital signs, indication for admission to the unit or positive blood cultures. The case was noted for a postoperative day 8 wound infection that had spontaneously opened and drained at home for which the patient presented to the emergency room (ER) for management. The patient was treated with IV clindamycin and transitioned to oral clindamycin and Keflex given penicillin allergy. There would have been no indication for admission in this case for wound infection that was open given the lack of any signs of instability or sepsis. The patient was able to tolerate oral intake.
The patient could have received appropriate treatment at a lower level of care status.
Based upon a review of the medical records and the Milliman Care Guidelines (MCG) Health Guideline entitled "Obstetric and Gynecologic Disease," there would have been no medical necessity for admission to acute inpatient level of care. The patient did not have failure of outpatient treatment, did not have pelvic abscess, and did not have a surgical emergency. Therefore, there would have been no medical necessity for inpatient stay for the indication of obstetrical wound infection post cesarean.