Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Axillary abscess.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient came to the hospital with complaints of chest pain, right arm pain, and weakness for the past 2 days. The patient had been somnolent for 2 days and had not taken her insulin for the same amount of time. She developed a boil on her right underarm that had become increasingly painful. The boil was drained in the emergency department (ED). The patient had a heart catheterization 2 months before this presentation, which showed nonobstructive disease, and a normal ejection fraction. An echocardiogram 3 months before this presentation also showed a preserved ejection fraction with no regional wall motion abnormalities.
The vital signs included a temperature of 98.4 degrees Fahrenheit, a pulse rate of 95, and blood pressure of 115/77. The patient was in no apparent distress on the exam, with an unremarkable cardiopulmonary exam, normal mental status, and no focal neurologic deficits.
The laboratory studies showed a normal white blood cell count, hemoglobin of 8.9, stable renal function, and sodium of 126. The lactic acid level was 2; magnesium was low at 1.4. The blood glucose was measured at 431 on the chemistry panel and 359 per bedside glucose.
The principal admitting diagnosis was pseudo hyponatremia secondary to hyperosmotic hyponatremia. The hyperglycemia was attributed to medication noncompliance. Chest pain rules out was also one of the admitting diagnoses.
The patient was reinitiated on her long-acting and short-acting insulin and showed an improvement in the blood glucose values within hours of admission. The sodium level was calculated for hyperglycemia at 134. The patient had negative troponins and a normal electrocardiogram (EKG) from a chest pain standpoint, therefore this was unlikely to be an acute coronary syndrome; however, cardiology was consulted. Bactrim was started for treatment of the axillary abscess that was drained.
The patient was reassessed the next day and had glucose values of 205 and 215, with normal stable vital signs. The cardiology team concluded that the patient had atypical chest pain, and the acute coronary syndrome was ruled out. The right axilla abscess was attributed to recurrent hidradenitis suppurative. The medical team decided to consult infectious disease and surgery for the abscess.
The next day, the patient's vital signs were stable, the glucose was 150, and the white blood cell count was 4.6. The infectious disease specialist added Levaquin to the Bactrim and recommended follow-up. Surgery performed a bedside incision and drainage (I&D). She experienced recurrent burning chest pain and nausea with small amounts of bloody vomitus in the afternoon. She continued to have diffuse abdominal tenderness. The medical team started iron supplementation, increased the dose of Protonix, provided Maalox and Zofran, and ordered an ultrasound of the abdomen. The anticipated discharge was in 24 to 48 hours. The following day, her vital signs remained stable, and the patient had significantly improved glucose values. The right upper quadrant ultrasound showed mild common bile duct dilation with no gallstones. The suspicion was for diabetic gastroparesis causing the patient's symptoms.
The patient complained of nausea and vomiting and was unable to keep food down. The lab results looked stable, as did the vital signs. The medical team initiated treatment with Reglan and placed the patient on a clear liquid diet to be advanced as tolerated. The wound culture report showed no growth of bacteria.
The patient was released home with oral antibiotics and a twice-daily proton pump inhibitor (PPI). At issue is the medical necessity of an inpatient stay.

Yes. Inpatient hospitalization was medically necessary in this case. Based on the provided documentation, the patient had multiple medical conditions present concurrently, which increases the patient's risk for poor outcomes. The presence of an axillary abscess, which required incision and drainage, poorly controlled diabetes, with blood glucose values in the 400s, as well as persistent nausea, vomiting, and burning abdominal pain, precluding the patient's ability to take oral medications, satisfy criteria for inpatient level of care. The patient failed the lower level of care criteria based on the need to have surgical incision and drainage beyond the treatment in the ED. In addition, ongoing intravenous (IV) fluids for hyperglycemia, and nausea and vomiting related to diabetic gastroparesis, exceeded the lower level of care criteria. Without the patient's ability to tolerate oral antibiotics and adequate nutrition, treatment failure is inevitable. Therefore, it was reasonable and medically necessary for the patient to be hospitalized at an inpatient level of care for stabilization, monitoring of progress, monitoring of glycemic control, and electrolyte repletion before discharge.