Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders/Cellulitis/Breasts
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay due to the lack of medical necessity. 
The health plan's determination is overturned.

This patient is a female with no significant past medical history (PMH) who presented with bilateral breast pain, foul smelling discharge and fever. She had breast reduction surgery performed and bilateral drains were placed. She was given prophylactic antibiotics and the antibiotics are discontinued and the drains were removed. The patient had increasing redness and pain and was started on Bactrim two weeks ago for a suspected surgical infection, but she developed worsening pain and swelling, as well as fever. She also developed nausea, one episode of emesis and 3 loose watery stools on the day of admission. She presented to the emergency department (ED) and was found to have a foul smelly discharge. She was tachycardiac with a heart rate (HR) >130 beats per minute (bpm) and initially had a blood pressure of ~120/80 millimeters of mercury (mmHg). She had a fever of 102.3F. The patient had no leukocytosis that was thought to be due to masking from the antibiotics. She had an elevated lactate of 3 and had mildly elevated troponins. She became hypotensive with systolic blood pressures in the 80's mmHg. She was given intravenous (IV) hydration, IV Vancomycin and IV Clindamycin. She also developed a rash and itching, requiring IV Benadryl. It was thought to be due to Vancomycin. Therefore, the Vancomycin was stopped. The patient was admitted to the step-down unit and was maintained on IV antibiotics. There was no growth on the blood cultures. Imaging did not show any abscess. She improved with the treatment and subsequently was discharged home on oral antibiotics.
At issue is the medical necessity of the inpatient stay.

I overturn, in whole, the health plan's determination of medical necessity.

Based on the review of the records, medical literature and current best practices, the health plan did not act reasonably in its determination of the medical necessity. This is a female who had a surgical site infection (SSI) after bilateral breast reduction surgery. She was initially seen in the clinic for SSI and was started on Bactrim. As per the ED note, she was on Bactrim for more than a few days, but despite that she continued to get worse and developed a fever, nausea, vomiting and diarrhea. She also had high grade fever of 102.3F, tachycardia (132bpm, and an elevated lactic acid. The patients who have evidence of systemic toxicity such as sustained tachycardia, fever >100.5F., hypotension (all present in this patient), the patients who have received oral antibiotics for 48 hours and despite that progressed (as in this patient) should be admitted and management with IV antibiotics [1,2]. Moreover, the patient met the criteria for severe sepsis (lactic acidosis, acute kidney injury, mild treponema, hypotension), are at high risk of decompensation and should be managed aggressively with IV resuscitation and broad-spectrum antibiotics [3]. Based on these observations, I believe the health care plan's determination of medical necessity in this patient is not reasonable.