Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep incisional surgical site infection
 
Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services.  The denial is upheld. 

This patient is a male with a history of obesity, gastric bypass surgery, hypothyroidism, gastroesophageal reflux disease (GERD) and sleep apnea.  The patient was status post laparoscopic band procedure several years ago.  This patient presented to the Emergency Department (ED) with complaints of pain and swelling from the mid abdominal area.  He complained of 2-3 weeks of abdominal pain from a previous laparoscopic band.  He also endorsed intermittent fevers, chills and was scheduled for port removal.  He presented and was afebrile with stable vital signs.  Two days prior to presenting to the ED, the patient noted increased redness and purulent discharge from the port site.  On exam, he had a soft non distended abdomen with erythema and pus discharge from the port site with fluctuance and tenderness over the site.  The white blood cell (WBC) count was 6.7.  A CT of the abdomen on the day that he presented revealed a small air fluid collection along the subdiaphragmatic course of the proximal laparoscopic band tubing and inflammatory changes along the remainder of the tubing to the level of the port.

Fat stranding and skin thickening around port without a definite focal fluid collection was also reported.  The plan was surgical intervention.  Surgery saw the patient at early night with the assessment of infection following a procedure, deep incisional surgical site.  The patient was taken to the Operating Room (OR) and underwent a removal of the laparoscopic band port, subcutaneous component only.  The patient refused to have the whole laparoscopic band removed, and as such, only the port was pulled from the surrounding tissue up to a point on the tubing where it was felt that it had some tightness to the abdominal wall.  Postoperatively, he did well and was afebrile.  He was discharged home on oral Flagyl and Cefdinir.

This patient did not meet the criteria for inpatient admission as there was no fever or severe infection as he had a localized infection and had a normal WBC count.  He was hemodynamically stable and he was not septic.  The procedure that he underwent was an incision and drainage of the abscess with removal of the port hardware.  All of this could have been done without an acute inpatient admission.  Therefore, the patient could have been treated on an observation status.

Finally, according to MCG Health General Recovery Care 23rd Edition Wound and Skin Management GRG: PG-WS (ISC GRG) continued inpatient stay is needed until 1 or more of the following are present: Acceptable patient status for next level of care is achieved with ALL of the following  present: Temperature status acceptable; No infection, or status acceptable; Pain and nausea absent or adequately managed; Wound and ulcer problems absent or status acceptable; No burn injury, or status acceptable; Traumatic injury absent or status appropriate; Skin disease absent or status appropriate; Activity level acceptable; Intake acceptable; No inpatient interventions needed; General Discharge Criteria met. Thus, this patient could have been treated in an ambulatory status with observation.  He did not require an acute care admission and only observation level of care as he did not have an acute medical condition that required inpatient status.

Therefore, based upon the clinical information provided, the inpatient admission was not justified at the acute level as the patient could have been treated in an outpatient/ observation status.  The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.