Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is the case of an adult female with no significant medical history who presented to the emergency room (ER) with complaints of 10 out of 10 pain from a left breast lesion.   Symptoms began 3 weeks prior to arrival. She denied fever or chills but reported worsening symptoms. As per the ER triage note the patient was afebrile with stable vital signs. On exam the patient had a fluctuant tender 3 x 3 centimeter lesion in the right upper quadrant of the left breast. There was no purulent discharge or bleeding. The impression was left breast abscess versus another lesion. Surgery saw the patient and noted the patient presented with left breast pain and swelling for the past 3 weeks. The patient reported she had attempted management with antibiotics without relief of symptoms. She had been referred to a breast clinic with workup to include mammogram and breast ultrasound. On imaging she had findings of confluent bands of heterogenous fluid seen, associated with skin thickening and vascularity in the surrounding tissues, probably representing a resolving infectious/ inflammatory process versus a neoplastic or other process. Exam revealed an area of redness, tender to palpation with fluctuance and induration. The white blood cell (WBC) count was 9.9. The plan was IV (intravenous) antibiotics and for her to be an add-on case for surgery. 

The patient was taken to the operating room and underwent an incision and drainage (I & D) of a left breast abscess. The wound was packed with iodoform gauze and dressing placed. She was transferred to the post anesthesia care unit (PACU) and then to the surgical floor in stable condition. 

According to MCG Health General Recovery Care 25th Edition General Admission Criteria GRG: admission is indicated for 1 or more of the following: Hemodynamic instability; hypertension requiring inpatient treatment; acute cardiac or peripheral ischemia; cardiac arrhythmias of immediate concern; severe heart failure; severe respiratory findings; severe airflow or ventilation abnormalities; impending or actual respiratory arrest; neurologic abnormalities; new-onset severe neurologic findings; suspected acute intra-abdominal process; severe physiologic disorder; abdominal abnormalities; acute renal failure; significant uremic complications; high fever or other high-risk infection situation; temperature less than 95 degrees Fahrenheit (F)/35 degrees Celsius (C); severe electrolyte abnormalities requiring inpatient care; acute blood loss;...emergency procedures needed. 

The patient had a localized infection without fever and without a WBC elevation, that required an incision and drainage. In this case, the patient could have had the drainage of the abscess and been placed on oral antibiotics and discharged without an acute inpatient admission. She was not a diabetic. She did not have a high WBC or fever. She could have had the abscess drained and been sent home without an acute care stay. She could have been kept on a 23 hour observation following the procedure, if necessary. This patient did not meet the criteria for inpatient admission as she had none of the indications that would have required inpatient services/admission. The abscess drainage was amenable to outpatient or observation care.

Based on the submitted documentation and MCG guidelines, the inpatient admission was not considered medically necessary treatment for the patient's condition.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient.

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