Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history of poorly controlled diabetes with a hemoglobin (HGB) A1c of 10%, morbid obesity, hypertension, and a ventral hernia repair, who presented to the emergency department with abdominal pain in addition to subjective chills, fevers, nausea, and two episodes of non-bloody emesis.
On presentation, she was febrile to 101.4 degrees Fahrenheit with blood pressure 130/60, heart rate 106, respiratory rate 21, and with oxygen saturation 97% on room air. Her exam otherwise noted a lower abdominal scar with tenderness, erythema, warmth, induration and some fluctuance without rebound or guarding. Labs resulted with a white blood cell count (WBC) of 12.3, HGB 11.5, platelets 354, sodium 131, potassium (K) 3.1, blood urea nitrogen (BUN) 8, creatinine 0.76, glucose 385,and albumin 2.5 with the rest of the patient's liver function tests within normal limits, troponin undetectable, and lactic acid of 2.5 with repeat 1.4. A computed tomography (CT) scan of the abdomen and pelvis showed 13.9 centimeter (cm) hernia with multilocular air and fluid collection consistent with an abscess. A chest x-ray showed no acute process. An electrocardiogram showed sinus tachycardia. A urinalysis did not reveal obvious evidence of an infection. The patient was given intravenous (IV) fluids, IV Zosyn, IV vancomycin, and anti-emetics in the emergency department and brought into the hospital with concerns for abdominal wall abscess and sepsis and plans for ongoing IV fluids, IV antibiotics, follow up blood cultures, and a surgery consultation. Surgery subsequently recommended an interventional radiology consultation for potential drainage.
She remained hemodynamically stable without hypotension, tachycardia, or tachypnea. The WBC was 10.2 with glucose in the 200s. She underwent an uncomplicated ultrasound-guided percutaneous drainage of the abdominal wall abscess. Lantus was added.
Her exam noted abdominal tenderness. She was tolerating a diet without nausea or vomiting. The WBC was 10.1. The preliminary culture results of her abdomen were growing gram negative rods. The ongoing plan of care was IV antibiotics and tailoring antibiotics after wound culture results.
The patient was ultimately discharged.
The issue for review is whether an inpatient level of care was medically necessary.
The requested health service/treatment of inpatient stay was medically necessary for this patient. This is a patient with poorly controlled diabetes with a HGBA1c of 10% and glucose of 385 on presentation, in addition to morbid obesity, who presented with a large abdominal abscess accompanied by fever and leukocytosis. She was very high risk given her poorly controlled diabetes and her morbid obesity for failure to respond to therapy and progression to sepsis and required very close monitoring of her glucoses and change in her glucose management with the addition of Lantus on top of requiring IV antibiotics, IV fluids, drainage of her abscess, and need for culture data prior to discharge to ensure proper treatment in the outpatient setting. Given her presentation and risk, she could only be safely cared for in the inpatient setting.