Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hidradenitis suppurativa.
Treatment: Inpatient Hospital Services.

The insurer denied the inpatient hospital services.  The denial is upheld.

The patient is a female with medical history significant for multiple episodes of left axillary abscess status post incision and drainage (recurrent and chronic hidradenitis suppurativa), who presented to the emergency department (ED) with chest pain. The pain began three days prior and was rated 4/10, located in the substernal mid chest region, described as sharp and non-radiating. She also reported some mild shortness of breath. Breathing exercises provided some relief.

She was admitted to the Surgical Service for observation and possible surgical intervention. Admission orders included nothing by mouth, intravenous (IV) fluids, ciprofloxacin, sequentials for deep vein thrombosis (DVT) prophylaxis, plans for surgical intervention the following day. She was taken to the operating room (OR) for incision, drainage, and washout of axillary abscess secondary to severe hidradenitis suppurativa. Post-operatively, she had low-grade temperature 100.5 Fahrenheit (F) but was otherwise stable and feeling better. Preliminary cultures included Escherichia (E.) coli and Enterococcus (E.) faecalis sensitive to fluoroquinolones. The wound packing was changed with morphine premedication. Her diet was slowly advanced, and she was encouraged to ambulate. She was deemed stable to discharge later, to complete a course of ciprofloxacin for a total of fourteen days. The subject under review is the medical necessity for the inpatient hospital services.

The health plan's determination is upheld.

Inpatient hospital services were not medically necessary for this patient.

Hidradenitis suppurativa is a chronic skin condition affecting apocrine gland-rich skin regions. It is an inflammatory condition that has proven to be difficult to manage and can cause significant pain and suffering for those affected. The lesions present as nodules, sinus tracts, or abscesses, more likely to occur in females, and more common after onset of puberty. There is frequently a family history, suggesting some type of genetic predisposition (e.g., mutations in gamma-secretase complex genes). Risk factors include obesity and smoking. Based on the standard of care, treatments have included topical clindamycin, combination therapy using hyperbaric oxygen and systemic antibiotic therapy (rifampicin, clindamycin). Intralesional injection of glucocorticoids can be beneficial. Anti-androgens may be useful in female patients. Administration of systemic immunosuppressive medications such as cyclosporine, tumor necrosis factor inhibitors (e.g., adalimumab), phosphodiesterase-4 inhibitors, and anti-interleukin-17A antibodies have been used, with adalimumab showing promising results. A staging algorithm (Hurley I-III) has been used as a guideline for treatment. Based on this algorithm, surgical intervention is reserved for unresponsive cases.

This patient had undergone multiple surgical procedures in the months leading up to this admission. She presented to the ED with chest pain. The CT (computed tomography scan) was suggestive of persistent fluid collection. She was admitted to the surgical service for observation and surgical intervention. While it was not unreasonable to monitor her in the hospital, provide parenteral antibiotics, and arrange for surgical drainage, she was overall hemodynamically stable with no evidence of intractable severe pain. She did not require acute inpatient admission and could have been safely managed at a lower level of care.