Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left breast pain with chills, erythema and
incision drainage
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. This patient had undergone abdominoplasty, left breast reduction and bilateral silicone breast implant placement . She presented to the ED (emergency department) a few days later with complaints of worsening left breast pain with chills, erythema and incision drainage. 

The patient's exam in the ED (emergency department) identified skin necrosis of the left breast with erythema. She was admitted to the hospital and treated with antibiotics, pain control and consults with interventional radiology and infectious diseases. She was treated with aspiration of her left breast fluid collection. The patent signed out AMA (against medical advice) the following day. 

No, the Inpatient admission was not medically necessary.

The patient presented to the hospital with an infected left breast implant. Plastic surgery evaluated her. The consult note states that surgical intervention is not indicated. Interventional radiology drainage of the fluid collection, antibiotic treatment and follow-up as an outpatient is recommended. Interventional radiology successfully aspirated the fluid.  Infectious disease consultant recommended discontinuation of all antibiotics at this point and follow-up. 

According to the Milliman Care Guidelines, 24th Edition, "General Admission Criteria," Admission is indicated for 1 or more of the following:
Hemodynamic instability
Hypertension requiring inpatient treatment
Acute cardiac or peripheral ischemia
Cardiac arrhythmias of immediate concern
Severe heart failure
Respiratory abnormalities
Severe airflow or ventilation abnormalities
Impending or actual respiratory arrest
Neurologic abnormalities
New-onset severe neurologic findings
Suspected acute intra-abdominal process
Severe physiologic disorder
Abdominal abnormalities
Acute renal failure
Significant uremic complications
High fever or other high-risk infection situation
Temperature less than 90 degrees F (Fahrenheit) (32.2 degrees C [Celsius]) (rectal)(61)
Severe nutritional abnormalities
Severe electrolyte abnormalities
Acute blood loss causing significant abnormality
Severe anemia
High-risk low platelet count
Disseminated intravascular coagulation
Severe adverse drug or systemic toxin reaction requiring inpatient treatment
Severe pain requiring acute inpatient management
Severe behavioral health issues
Inpatient monitoring needed; examples include:
1) Vital signs, neurologic signs, or vascular checks more frequently than every 4 hours
2)Cardiac or respiratory monitoring beyond the scope (eg, over 24 hours) of observation care
3) Pulmonary artery catheter monitoring
4) Suspected compartment syndrome
5) Cerebral bleeding, hydrocephalus, or vasospasm monitoring
6) Increased intracranial pressure or cerebral edema monitoring
7) Fetal monitoring
Treatment requiring inpatient care; examples include:
8) IV (intravenous) fluid to replace significant ongoing losses (greater than 3 L/m2 [liters per meters squared] per day)
9)High concentration oxygen (greater than 40%)
10) Frequent respiratory therapy (more frequently than every 4 hours) to maintain airflow rates greater than 60% of baseline
11) Epidural analgesia(83)
12) IV (intravenous) anticoagulation, vasoactive, or antiarrhythmic medication
13) Acute thrombolytics (generally require 24 hours of observation) Emergency procedures needed

This patient did not have any of these conditions. The notes do not document a need for inpatient admission. Antibiotics were discontinued, and surgery was not indicated. She could have been treated with aspiration of her fluid collection and follow-up with her infectious disease and plastic surgery physicians at a lower level of care.