Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infection, wound
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is an adult male who presented to the hospital with worsening swelling, redness and pain on the left thigh.  He had been seen two days prior for an infection in the thigh that was thought to be related to a furuncle that progressed and he was provided Bactrim treatment orally. There was no report that the patient did not take the prescribed Bactrim.  He had considerable pain, documented multiple times as 7 out of 10 when he presented to the ER (emergency room).

The patient received pain medications, IV (intravenous) fluids and antibiotics IV (intravenous).  His white cell count was mildly elevated.  A large area of induration was noted on the anterior thigh, 10 cm (centimeters) by 6 cm (centimeters), with no clear fluctuant abscess.  Imaging with CT (computed tomography) also did not demonstrate a definitive abscess.  The patient underwent antibiotic treatment, analgesia, IV (intravenous) fluid administration, ID (infectious disease) consultation, and ultimately surgical consultation resulting in bed-side incision and drainage of a purulent abscess in the anterior thigh region.  This was packed and antibiotics were continued.  The patient was discharged home in stable condition on oral antibiotics.

The insurer states the patient could have had drainage done in the ER (emergency room) or observation setting and then be discharged home in stable condition.

Yes, the inpatient admission was medically necessary.

The patient had failed outpatient antibiotic treatment with an appropriate antibiotic, Bactrim, for an appropriate duration of time, 48 hours.  With lack of microbiologic data available and lack of response to appropriate outpatient therapy, it was important to treat broadly with vancomycin and ceftriaxone both.  Since oral regimen had failed previously, intravenous antibiotic was thought to be more appropriate and this reasoning is justified since a larger dose can be delivered parenterally than orally.  Further, the patient's infected area spanned 10 by 6 cm (centimeters), increasing the risk of systemic compromise or systemic bacteremia.  The larger the burden of infection, the larger the risk of dissemination.  Drainage required a specialized physician, a surgeon, who is not readily available in the outpatient or observation setting.  ID (infectious disease) consultation was also sought and is not expeditiously available in the outpatient setting.  The patient also had severe pain, which raised the specter of potentially a necrotizing infection.

These multiple factors support that it was not safe for the patient to be discharged from an observation setting.  Not only did the patient need expeditious surgical consultation and incision/drainage, he also needed a period of time to observe clinical response to ensure that his infection was not penetrating or deeper than initially thought and parenteral antibiotics were needed, in addition to ID (infectious disease) consultation.  All these measures could not have been expeditiously accomplished in the observation or outpatient setting.  The severity of illness and intensity of services and evaluation/management needed for this patient justifies inpatient hospitalization.  As such, the inpatient hospitalization was medically necessary.