Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perirectal Abscess. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

According to the documentation submitted, this is an adult with a history of obesity, anxiety, depression, and marijuana use. The patient's colorectal surgeon instructed the patient to come to the emergency department (ED) for further evaluation and a computed tomography (CT) scan because of rectal pain. As per the triage note the patient presented to the ED and was afebrile with stable vital signs. He had rectal pain for 1 week and he was sent to the ED to determine if it was an abscess or fissure. He complained of itching and severe pain when moving his bowels. As per the ED provider note the patient has been having rectal pain for the last few days. He followed up with a colorectal surgeon who instructed him to come to the ED. He also stated he developed an itchy rash to his right upper extremity and anterior chest which appeared to be urticaria. On exam he appeared in no apparent distress. His abdomen was soft and non-tender. His White blood cell (WBC) count was 14.7. A CT of the abdomen/pelvis showed a 1.6 x 2.1 x 2.1 centimeter (cm) peripherally enhancing fluid collection in the perianal area which likely represents an abscess. He was evaluated by colorectal surgery in the ED and the patient was to be admitted to colorectal service for intravenous (IV) antibiotics and likely procedure the next day. 

Based upon the information provided, the acute inpatient admission and stay was not medically necessary as the patient could have been treated in an observation stay. The patient had a perirectal abscess that underwent incision and drainage (I and D) after being sent to the hospital by his provider for a CT and evaluation. He should have had the procedure on the first hospital day. He did not have it until late on the second hospital day and then was kept in the hospital for care because of a rash that had developed prior to him receiving antibiotics. This rash was most likely due to a bad batch of marijuana. Nevertheless, he did not need an acute admission for the rash either. The insurer is correct in denying the full hospital admission as the patient did not meet the criteria for acute admission. He was stable and could have been observed and discharged following the I and D and without an acute admission but rather a 23-hour observation stay. 

According to Milliman Care Guidelines (MCG) Health General Recovery Guidelines 26th edition General Surgery or Procedure GRG: SG-GS (ISC GRG), Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; including Stoma repair, Fistula repair, Lymph node surgery; Hernia repairs in the absence of ALL of the following: Emergency procedure (strangulated hernia), Severe co morbid disease (severe infection), Complex approach (morbid obesity, large chronic incarceration); Hemorrhoid or rectal surgery; Most breast procedures; Percutaneous and dilation procedures; and Liver biopsy. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.