Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented to the Emergency Department (ED) from home with complaint of progressively worsening abdominal pain and right-sided back pain. Of significant importance, the patient had recently undergone liposuction in another country. Pre-hospital medication included Toradol with minimal relief. The patient also reported that she had been taking Levaquin and Clindamycin since the surgery (prescribed by provider in the other country). Of note, the patient was previously evaluated in the ED with complaint of dizziness. At that time, she was found to be Anemic requiring transfusion of two units packed red blood cells. The patient was discharged from that ED visit with instructions for outpatient follow up.

Upon arrival for the visit under review, the patient's vital signs were blood pressure 99/55 mm Hg (millimeters of mercury), temperature 98.1, pulse 72, respiration rate 18, with a pulse oxygen saturation level of 100% on room air. Her abdominal pain is said to be a 7/10 in intensity. On exam, there is notable right lower quadrant abdominal swelling. Abnormal lab values include WBC (white blood count) 10.33 with 73% Neutrophil Shift, ANC (absolute neutrophil count) 7.55, and Hgb (hemoglobin) 11.0. Abdominal CT (computed tomography) Scan revealed increased subcutaneous stranding and bilateral fluid collections most pronounced in the right anterolateral abdomen. The presence of superinfection could not be entirely excluded.

In the ED, the patient received Intravenous (IV) Fluid Bolus of 0.9% Normal Saline 1000 ml (milliliters) STAT (immediately), followed by continuous IV Fluids, Lactated Ringers to infuse at 100 ml/hour, IV Ketorolac 15 mg (milligrams) STAT (immediately), IV Piperacillin/Tazobactam STAT (immediately), and surgery consultation was obtained. As per surgery, abdominal CT revealed large ventral abdominal fluid collections with possible multiple subcutaneous abscesses status post liposuction procedure.

During the patient's hospital course, serial labs were performed with close monitoring of WBCs. The patient received IV Clindamycin 600 mg every eight hours, Amoxicillin and Clavulanate 875 mg-125 mg PO (by mouth) every 12 hours, and her pain was managed with IV Hydromorphone 0.5 mg every four hours as needed for moderate to severe pain, and Oxycodone 5 mg PO every four hours as needed for moderate pain.

The patient underwent Bilateral IR (interventional radiology) Drainage of Fluid Collections, and Bilateral Drains were placed.

On hospital day number 2, wounds continued Serous (right 75 ml) and Serosanguinous (left 30 ml) drainage. As per surgery, continue to monitor output and insertion sites. Leukocytosis resolved, and the patient's pain improved. Having met maximal hospital benefit, the patient was judged medically stable, therefore was discharged to home. The patient was taught how to empty drains, monitor output, and care for insertion sites.

No, the inpatient admission was not medically necessary.

The patient could have been managed at an observation level of care while the acuity of her illness was being worked up. According to MCG (Milliman Care Guidelines) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically it is 48-hours or less, but can be up to 72-hours in certain situations."

This patient's physicians were concerned that she had a superinfection from her
liposuction, but she was not septic at presentation. Observation status would have
allowed her physicians to gather additional information.

According to the Milliman Care Guidelines, 24th Edition, "General Admission Criteria," admission is indicated for 1 or more of the following:

1) Hemodynamic instability 2) Hypertension requiring inpatient treatment 3) Acute cardiac or peripheral ischemia 4) Cardiac arrhythmias of immediate concern 5) Severe heart failure 6) Respiratory abnormalities 7) Severe airflow or ventilation abnormalities 8) Impending or actual respiratory arrest 9) Neurologic abnormalities 10) New-onset severe neurologic findings 11) Suspected acute intra-abdominal process 12) Severe physiologic disorder 13) Abdominal abnormalities 14) Acute renal failure 15) Significant uremic complications 16) High fever or other high-risk infection situation 17) Temperature (rectal) less than 90 degrees F (Fahrenheit) (32.2 degrees C [Celsius]) 18) Severe nutritional abnormalities 19) Severe electrolyte abnormalities 20) Acute blood loss causing significant abnormality 21) Severe anemia 22) High-risk low platelet count 23) Disseminated intravascular coagulation 24) Severe adverse drug or systemic toxin reaction requiring inpatient treatment 25) Severe pain requiring acute inpatient management 26) Severe behavioral health issues 27) Inpatient monitoring needed; examples include: a) Vital signs, neurologic signs, or vascular checks more frequently than every 4 hours b) Cardiac or respiratory monitoring beyond the scope (eg, over 24 hours) of observation care c) Pulmonary artery catheter monitoring d) Suspected compartment syndrome e) Cerebral bleeding, hydrocephalus, or vasospasm monitoring f) Increased intracranial pressure or cerebral edema monitoring g) Fetal monitoring 28) Treatment requiring inpatient care; examples include: a) IV fluid to replace significant ongoing losses (greater than 3 L/m2 [liters per meters squared] per day) b) High concentration oxygen (greater than 40%) c) Frequent respiratory therapy (more frequently than every 4 hours) to maintain airflow rates greater than 60% of baseline d) Epidural analgesia e) IV anticoagulation, vasoactive, or antiarrhythmic medication f) Acute thrombolytics (generally require 24 hours of observation) g) Emergency procedures needed.

This patient did not have any of these conditions. She required IV fluids, pain medication, IR aspiration and a diagnostic work-up, all of which could have been completed at an observation level of care.