Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tubular adenoma. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

This female patient has a past medical history of gastric polyps and has been diagnosed with a tubular adenoma. She was admitted to the hospital and underwent a total gastrectomy. She tolerated the procedure well and was admitted for postoperative care for pain control and nutrition. She was slowly advanced in diet. During her stay, she had a low grade fever and was placed on Bactrim for treatment of a suspected incisional infection, and then vancomycin. Her wound was opened and cleaned with wound vacuum-assisted closure (VAC) placed. She was given several doses of intravenous (IV) Toradol for pain. Persistent drainage was noted from the wound VAC. Her pain medications were changed to oral Tylenol and oxycodone. She also had diarrhea; stool cultures were negative. She remained afebrile. Her wound was noted to be erythematous. By the date of discharge, her wound was noted to no longer have erythema and she was discharged to home. 

This patient had signs and symptoms of a postoperative wound infection. She had a fever and her wound was opened with placement of a wound VAC. She was given additional dosages of broad coverage antibiotics. 

Surgical site infection (SSI) occurs in 4% of clean surgical incisions. The diagnosis of a SSI is clinical and signs can include erythema, pain, fever, purulent drainage and separation of the wound. With low grade, fever, open wound and erythema at the surgical site, this would meet criteria for a SSI. The management of a SSI includes exploration, irrigation and drainage possible in conjunction with antibiotics depending on the extent of infection, comorbidities of the patient and systemic manifestation.  Wound care is then implemented with dressings and negative pressure (wound vacuum) to assist in fluid removal and prevent further skin breakdown. 

Wound complications remain a significant cause of early and late postoperative complications and aggressively treating them is important. This patient had early signs of postoperative wound infection and was treated aggressively. This delayed discharge. This was appropriate care. Early discharge of an inadequately treated postoperative wound can lead to worsening infection, and worse clinical outcomes, such as necrotizing fasciitis, sepsis, and ultimately mortality. 

"Surgical site infections (SSIs) result in delayed wound healing, increased use of antibiotics and increased length of hospital stay, putting remarkable physical and financial burden on patients, their relatives and the healthcare facilities." (Tabiri et al 2018). 

"Surgical site infection was associated with increased length of postoperative stay. Moreover, an increased operative time was associated with both higher SSI rate and prolonged postoperative stay." (Alkaaki et al 2019). 

"For treatment, each surgical specialty, body region, and operation type needs to have its strategy to treat the already developed SSI as the microbial spectrum is often different. Also, foreign bodies (mesh, implant, metalwork) have to be considered for removal due to biofilm formation. Source control remains important, with the appropriate selection of antibiotics based on the type of surgical procedure performed, and the expected microbial causes for the infection. Often early surgical debridement is the preferred option to resolve infection successfully." (Zabaglo et al 2020). 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity is substantiated. The carrier's denial of coverage for the inpatient hospital admission is overturned.