Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain, Emesis, and Abscess
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with past history including previous episodes of abscesses. He presented with triage complaints of Chest Pain, Emesis, and Abscess (left buttock). Patient reported that for the prior three days, he had been having pain on left buttock consistent with a previous abscess. He reported 10/10 pain in left buttock without drainage. He denied injury or witnessed insect bite. Associated symptoms included fever, chills, chest pain, and emesis x (times) 4. Chest pain began after vomiting. Chest pain was in lower chest, constant, aching, non-radiating. The patient endorsed that for approximately three days he had consistent left buttock pain consistent with a previous abscess, in which the pain was rated as 10/10 with associated fever, chills, and chest pain which began after multiple episodes of vomiting. He is a smoker, drinks on occasion, denies drug use. Patient underwent CT (computed tomography) scan that showed left gluteal cellulitis with overlying skin breakdown. Patient underwent incision and drainage and was started on treatment with IV (intravenous) antibiotics and admitted to medical floor.

Pertinent findings on Examination showed that the patient was in significant discomfort when ambulating or sitting on buttocks. Examination showed large 5x5 cm (centimeter) area of fluctuance with surrounding erythema that was exquisitely tender to touch; located left of gluteal folds.

The patient was treated with a GI (gastrointestinal) cocktail for possible gastritis, incision and drainage of his gluteal abscess, and intravenous antibiotics within the ED (emergency department). The ED physician ordered labs as well as CT of the abdomen and pelvis which demonstrated left gluteal cellulitis and skin breakdown. Patient recovered and was discharged.

Yes, the inpatient hospital admission was medically necessary.

The patient had symptoms of fever and chills x 4 days on presentation. He also had complaints of vomiting x 4 before presentation. The patient also had previous episodes of abscess in the past. Patient continued to have symptoms of nausea on presentation. Patient also had complaints of chest pain on presentation. Patient has had prior episodes of the same in the past and required incision and drainage. Labs showed WBC (white blood cell) count of 13.2k on presentation. The treatment plan consisted of intravenous Ceftriaxone, intravenous Doxycycline, intravenous Vancomycin, intravenous Ancef, intravenous morphine for adequate pain control, Protonix and Zofran for gastritis, transthoracic echocardiogram which ruled out endocarditis, blood cultures, and close monitoring of the patient's signs and symptoms.

On admission to inpatient level of care, a more viable follow-up treatment plan could be formulated, and further morbidity and mortality could be prevented. All of this could not have been done in the outpatient setting. On presentation, patient had significant pain, fever/chills for 4 days and vomiting x 4 and labs showed elevated WBC, and exam showed big abscess that required drainage. Drainage of abscess, antibiotics and adequate care are the main features of inpatient treatment. In view of multiple episodes of vomiting and persistent nausea, the patient could not have been treated with oral antibiotics. Patient also had chest pain and required follow up troponin to ensure that acute coronary syndrome was ruled out. Patient required multiple treatment modalities and follow up to ensure that he was responding to treatment before he could be discharged. Completion of all of these treatments - follow up is not feasible in the outpatient setting or observation setting. Discharge after incision/drainage in the emergency room would have put the patient at risk for further deterioration, as he could not have been able to take oral antibiotics and tolerate oral intake in view of vomiting. Inadequate treatment of the abscess/cellulitis could lead to worsening cellulitis, turning into necrotizing fasciitis. Patient also required wound care to ensure continued improvement.

This patient's clinical presentation establishes the medical necessity of inpatient care in accordance with clinical literature, referenced below.