Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld.

This is the case of an adult female with a past medical history of fibromyalgia, rheumatoid arthritis, gastric bypass surgery, hypertension (HTN), and staged panniculectomy. As per the emergency department provider note the patient was s/p (status post) abdominal surgery and now complains of swollen legs, back and abdominal pain. The patient reported that the right sided drain fell out a week ago and she was seen in clinic a few days later with no complaints. Subsequently she noted weeping from her wound, clear fluid, and blood and then noted her thighs began to swell. She reported worsening shortness of breath and subjective chills and fever. She was afebrile with BMI (body mass index) 40.43 and BP (blood pressure) was 131/82. On exam her abdomen was soft with a surgical scar present and normal bowel sounds. There was no abdominal tenderness. The wound had erythema around the incision site with areas of granulation tissue and clear weeping. No bleeding was noted. There was a foul smell. The left side JP (Jackson Pratt drain) was in place. There was no pitting edema and no color changes to lower legs. The assessment was that since the drain fell out the suspected swelling to the thigh was related to fluid accumulation. She was evaluated for abscess or infection. A CT (computed tomography) revealed subcutaneous soft tissue fluid collection in the anterior abdominal wall with consideration for seroma, abscess or hematoma. Her hemoglobin (Hb) was noted to be 7.5 with baseline of 8 to 10. White blood cells (WBC) were 7. The plan was for the patient to be admitted to surgery for postop complication. 

According to the guidelines of  MCG (Milliman Care Guidelines) General Recovery Care- 26th edition Wound and Skin Management, GRG: PG-WS (ISC GRG) Surgery or other care covered by this guideline is indicated for 1 or more of the following: Skin lesion excision or other surgery needed, as indicated by 1 or more of the following: Melanoma; Other malignant tumor (e.g., basal or squamous cell carcinoma);  Benign lesion that is causing significant functional impairment; Benign tumor with recurrent infection not responsive to nonsurgical therapy; Severe hidradenitis suppurativa with tracts or abscesses; Pressure injury closure or other procedure needed (e.g., stage 3 or 4 ulcer not healing with conservative management); Insertion or replacement of device into soft tissue needed (e.g., replacement of defibrillator, pacemaker; Operative burn care needed (thermal, electrical, chemical, or frostbite); Lymphedema refractory to medical management (e.g., manual lymphatic drainage, intermittent pneumatic compression) requiring biopsy, debulking, or microsurgical procedure; Skin or tissue grafting needed (skin, flap, pedicle, or other tissue transfer graft), as indicated by: Skin disease or infection requiring inpatient care; Abdominoplasty or panniculectomy; Venous, arterial, neuropathic, or diabetic skin ulcer requiring inpatient care; Incision or drainage of skin or subcutaneous tissue (e.g., perirectal abscess); Wound debridement or complex care; Soft tissue debridement or exploration needed (e.g., bite); Postoperative complex wound care (e.g., necrotic surgical wound); Trauma care needed (e.g., amputation, compartment syndrome, degloving injury, severe necrosis.  In this case the patient could have been managed in an observation setting as she did not undergo any surgery at this time. She was admitted for monitoring of her wound and this could have been done in a monitored observation setting and not an acute inpatient admission.

Based upon these findings, the health care plan did act reasonably and with sound medical judgment in the best interest of the patient. The coverage for inpatient admission should be denied. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.