Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is overturned. 

The patient is a female with a past medical history of diabetes, hypertension, and hyperlipidemia, who presented for abscess of the right armpit and right gluteal area. The review of systems was negative for additional clinical symptoms. The patient was febrile (a temperature of 101.5) in the emergency department (ED). She was described as comfortable and in no acute distress. Her blood pressure was 143/64, pulse rate was 82, respiratory rate was 19, and oxygen saturation was 95% (percent) on room air. The physical examination was remarkable for an erythematous area of the right axilla and right gluteal fold.
The laboratory evaluation demonstrated a blood urea nitrogen (BUN) of 14, creatinine of 0.56, white blood cell (WBC) count of 14.8, hemoglobin (Hgb) of 11.36, and hematocrit (Hct) of 36.6. The computed tomography (CT) scan of the pelvis showed developing abscess/phlegmon of the right buttock skin with subcutaneous edema.
The patient was admitted for right axillary/gluteal abscess and cellulitis. The patient underwent an incision and drainage of the abscesses. The patient was treated with intravenous (IV) vancomycin. The hospital course was notable for continued purulent drainage from the abscess site. The patient was evaluated by a general surgeon and an extension of prior axially incision and drainage (I and D) site was performed with breakage of loculations and increased drainage of purulent material. Wound and blood cultures were negative. The patient was treated with IV Ketorolac and Tylenol for pain.
At issue is the medical necessity of the Inpatient Admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Admission was medically necessary for this patient.
The patient was admitted for abscesses of the axilla and gluteal areas in the setting of fever and leukocytosis which are signs of systemic inflammatory process. Additionally, the patient did not have adequate improvement after initial incision and drainage in the ED. The patient continued to have persistent purulent drainage requiring extension of incision and drainage by the surgeon. The documentation supports inpatient level of care for incision and drainage, IV antibiotics and pain medications.
Simple infections are usually confined to the skin and underlying superficial soft tissues generally respond well to outpatient management. However, complicated infections typically extend into and involve the underlying deep tissues including deep abscesses, decubitus ulcers, necrotizing fasciitis, and Fournier gangrene. These infections may present with features of systemic inflammatory response syndrome or sepsis, and, occasionally, ischemic necrosis. Perianal infections, diabetic foot infections, infections in patients with significant comorbidities, and infections from resistant pathogens also represent complicated infections. In this case, the patient's infection extended deep into the subcutaneous tissue and was recurrent despite prior drainage. The inpatient level of care was necessary for repeat incision, drainage and IV antibiotics given the presence of purulence and systemic signs of infection.
It is widely accepted in the literature that diabetics have an increased propensity to develop infections. Hyperglycemia causes both micro- and macrovascular complications, which are known illustrated as possible mechanisms that prevent the ulcers from wound healing. Blood glucose management is therefore considered a basic component of the treatment of wound healing. In this case, the inpatient level of care is appropriate for aggressive blood glucose control and expedited wound drainage.
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary.