Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Groin Abscess

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is an adult patient with no past medical history who presented to the emergency department with complaints of left sided groin localized swelling and pain that started approximately one week ago. As per the History and Physical, the patient complained of a lump for 1 week. The lump has been growing and it started draining on its own with opaque discharge. The patient tried to squeeze and get all the contents out. Some more purulent material came out of the lump and started getting larger again. It was not actively draining. There were multiple other scabs on the groin, and scrotum which are not tender. The plan was Unasyn, and scrotal sonogram. White Blood Cell Count (WBC) was 8.33. Potassium (K) was 2.9. Surgery was consulted. The patient was started on Cleocin. Scrotum of the sonogram showed a 3 cm (centimeters) heterogenous fluid collection in the left groin with findings suggestive of abscess.

The patient was taken to the operating room and underwent Incision and Drainage of left groin abscess under general anesthesia. Progress note indicated the patient was doing well. The wound was redressed and notably improved without surrounding induration or erythema. The patient was medically stable for discharge.

The patient did not have leukocytosis but hypokalemia. Potassium was replaced.  He did well and was discharged.  This patient could have been treated, if necessary, on oral antibiotics and discharged after a 23-hour observation with outpatient follow up. 

According to the guidelines of  Milliman Care Guidelines (MCG) General Recovery Care- 26th edition Wound and skin management Surgery 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. MCG notes that the operative Status Criteria is ambulatory for: Most skin lesion surgery; Most incision and drainage of skin or tissue; Most elective skin grafting; Partial thickness burn care for less than 10% (percent) of body surface area if not involving hands, feet, face, perineum, genitalia, or major joints. It is Inpatient: for other surgeries and procedures, inpatient stay will usually be needed because of 1 or more of the following: Inpatient procedure or Wound and Skin Procedures and Care AND 1 or more general admission criteria. In this case the surgery was uneventful, and the wounds were packed and therefore there was no indication for prolonged hospital care and for general admission criteria but rather observation.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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