Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Groin Cyst

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld.

The patient has a history of multiple sebaceous cysts requiring incision and drainage (I & D) who presented to the emergency department (ED) via ambulance with a groin cyst which caused severe pain and inability to ambulate. She was brought by emergency medical services (EMS). She denied fever and stated she had similar problems before and was drained. She reported that the cyst started 4 days prior and had grown and become erythematous. She was afebrile. On exam she had in the right inguinal crease a 5 x 2 fluctuant erythematous cyst with surrounding erythema and warmth extending to the upper thigh. It did not affect the labia. She was seen by general surgery who noted the above history and exam. White Blood Cell (WBC) was 13.12. She underwent in the ED, by the bedside, an I & D with packing placed.
	
Progress notes indicated the patient was afebrile and doing well. The dressing was changed. The patient continued on Unasyn. WBC was 10.54. She continued to do well and was ambulating without difficulty with pain well controlled. She was discharged with 7 day course of Bactrim and dermatology clinic follow up.

The inpatient admission and stay was not medically necessary as the patient could have been treated in an observation stay. The patient had a groin abscess that was I & D in the ED by the bedside and could have been sent home the following day after 23 hours of observation. She was afebrile and was ambulating. She did not require continued inpatient care and she could have been managed only with observation care. The care could have been done as an observation status and did not require an acute inpatient admission. 

According to MCG Health Inpatient and Surgical Care 25th Edition Cellulitis ORG: M-70 (ISC) Clinical Indications for Admission to Inpatient Care: Admission  is indicated for 1 or more of the following:  Hemodynamic instability; altered mental status that is severe or persistent; Failure of outpatient therapy; Limb-threatening infection;   Clinical presentation (e.g., acuity of infection, rapidity of progression) is judged to require intensity of patient monitoring (e.g. vital sign measurement, checks for infection progression) that cannot be provided at other than inpatient level of care; significant immunosuppression (e.g. long term systemic steroids, neutropenia);  Bacteremia (with a likely causative organism),  Suspected necrotizing soft tissue infection (e.g., gas in tissue), Severe oral cellulitis (e.g. Ludwig's angina), Surgical procedure needed (e.g., abscess drainage, debridement) not amenable to outpatient, emergency department, or observation care, Cutaneous gangrene, Orbital infection, Preseptal or perineal infection that is severe or progressive; Inability to maintain oral hydration (i.e. IV fluid support needed) , Compartment syndrome monitoring. This patient did not meet the criteria for inpatient admission as she had none of the indications that would have required inpatient services/admission. Her abscess drainage was amenable to outpatient or observation care.

The inpatient admission was not appropriate as her management did not require an acute inpatient admission. She could have had the abscess drained and sent home without an acute care stay. She did not need to be admitted for this.  She could have been kept on a 23 hour observation following the procedure, if necessary. The health care plan did act reasonably and with sound medical judgment. 

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