Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Axillary Hidradenitis. 
Treatment: Inpatient Hospital Admission. 
The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld. 

The patient is a female (body mass index (BMI) 35 kilograms per meters squared (kg/m2)) who presented to the hospital emergency department (ED) with a painful swelling of the right axilla of 2-weeks duration. She has a past medical history of hidradenitis suppurativa and prior infections. She had been treated in the outpatient setting with oral antibiotics without improvement. At the time of presentation to the ED there was a 5 by 7 centimeter (cm) area of induration and tenderness of the right axilla. She was without fever and her vital signs identified a heart rate of 89 beats per minute on the day of admission. The patient's white blood cell count (WBC) count was elevated at 13. She was admitted to the hospital. She was started on antibiotics and the surgery service was consulted. 

The day after admission the patient underwent an incision and drainage of the hidradenitis abscess of the right axilla. The patient had an uncomplicated post-surgical recovery and was able to be discharged from the hospital. She was continued on oral antibiotics post-discharge. 

The health plan denial letter states that the inpatient admission was not medically necessary based on Milliman Care Guidelines (MCG) -Medical. 

The health plan in its determination of medical necessity acted reasonably, with sound medical judgment and in the best interest of the patient. 

The acute inpatient admission was not medically necessary for this patient. The patient presented and was admitted to the hospital with an axillary abscess related to recurrent hidradenitis suppurativa. The submitted records support that the patient was clinically stable at the time of presentation. However, she did have a leukocytosis that was treated with intravenous (IV) antibiotic therapy and surgical drainage. On the day after admission the patient underwent a surgical incision and drainage. She was stable throughout the procedure and in the early post-surgical period such that she was able to be discharged from the hospital. 

An alternate level of care is indicated in the setting of a cutaneous abscess with elevated white blood count (WBC) count, failure of outpatient therapy when there is progression or no improvement after an adequate trial or if an outpatient intravenous therapy is not appropriate or not appropriate due to progression of infection, not available or cannot be arranged, need for immediate initiation of IV therapy, intensity of patient monitoring cannot be provided at other than inpatient level of care.

Clinical issues such as a limb threatening infection, high risk comorbid condition, bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection, high fever, severe pain requiring inpatient care, compartment syndrome, or other such conditions require inpatient care. In this case these criteria were not present as supported by the medical record. 

The alternate level of care would be appropriate for this patient. In this case, the patient could have reasonably and appropriately been treated with an alternate level of care with subsequent therapy provided in the outpatient setting.