Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Condition. 
Treatment: Inpatient Hospital. 
The insurer denied an inpatient stay. 
The denial is upheld in whole.

The patient is a female with a past medical history remarkable for diabetes and recurrent abscesses who presented to the hospital with a left groin abscess that had been going on for one week and a right breast abscess that started to drain three days before the presentation. The patient was referred to the emergency department by her primary care physician with a recommendation to receive treatment with intravenous antibiotics.

In the hospital, the patient was seen by an infectious disease specialist who was consulted for evaluation of recurrent abscesses. The infectious disease specialist recommended treatment with clindamycin for coverage. The infectious disease specialist recommended smoking cessation as well as additional laboratory studies to look for the reason for the recurrent abscesses.
During the hospital stay, the patient was seen by an endocrinologist who adjusted the patient's regimen of insulin as well as oral agents to achieve better control of diabetes mellitus.
In the hospital, the patient underwent incision and drainage of the left groin abscess. The patient underwent a computed tomography (CT) scan of the abdomen and pelvis, which was negative for pelvic mass or any adnexal pathology.
In the hospital, the patient was seen by nephrology because of hyperkalemia, however, the repeat laboratory evaluation demonstrated normal serum potassium levels.
Since the patient's clinical condition improved, she was transitioned to outpatient care with oral antibiotics.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

Based on the nationally accepted criteria, admission at the inpatient level of care for patients with soft tissue infections is generally indicated in cases of failure of outpatient therapy, in cases of rapid progression of the infection necessitating high intensity of patient's monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus, or liver cirrhosis.
In this clinical case, the patient's diabetes mellitus was not optimally controlled, however, the hemoglobin A1c was 8.6, which is much lower than the definition of uncontrolled diabetes, which means hemoglobin A1c is greater than 10%.
The admission at the acute inpatient level of care is also indicated for patients with soft tissue infection and bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, or when patients need a surgical procedure not amenable to outpatient or emergency department care.
In this specific case, the patient underwent incision and drainage of the groin abscess performed under local anesthesia. Therefore, there was no strong evidence that this procedure was not amenable to outpatient or emergency department care. Furthermore, there was no strong evidence that the patient had severe pain that required acute inpatient management. There was no mention that this patient was unable to maintain oral hydration.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
The patient could have been managed at a lower level of care status.