Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scrotal cellulitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
This adult patient has a history of diabetes mellitus (DM), hypertension (HTN), benign prostate hypertrophy (BPH), hypothyroidism, and glaucoma. The patient presented to the Emergency Department (ED) due to dysuria and scrotal rash with pruritus. Exam noted redness on the patient's scrotum and lab noted abnormal urinalysis. The patient was admitted due to scrotal erythema with cellulitis. The patient received antibiotics, Diflucan and had a urology consult. 

Scrotal cellulitis can be treated as an outpatient or observation status. Furthermore, there was no evidence of Fournier's gangrene or abscess. In this case, the care could have been done under observation status. 

"Scrotal pain, in both its acute and chronic forms, is a diagnostic challenge that must be carefully evaluated with a full patient history and physical examination. Pain, the dependent nature of the scrotum, and the edema and skin changes that accompany many scrotal pathologies may prevent a complete examination. The patient's age, sexual history, and duration, severity, and onset (gradual vs. sudden) of pain are necessary to focus the clinician's attention on the correct diagnostic path. In its acute form, scrotal pain is a medical emergency requiring prompt attention to rule out testicular torsion. The physical exam must include a careful evaluation of the abdomen and inguinal region and a genital exam to assess possible herniation." (Gordhan, C. G., Sadeghi-Nejad, H., 2015).

"Fournier's gangrene (FG) is a perineal and abdominal necrotizing infection. It is most commonly found in middle-aged men with comorbidities such as diabetes mellitus. Initial symptoms are often indistinct and can rapidly progress to overwhelming infections with a relatively high mortality rate. It is crucial to make a prompt diagnosis so that the patient receives appropriate treatment. Given the importance of the identification of FG, we explored what were the most common signs and symptoms associated with FG, as well as distinguished the gold standard treatment. This systematic review utilized articles identified exclusively through PubMed using key terms such as Fournier's gangrene, signs, symptoms, and treatment. A total of 37 studies, including a total of 3,224 patients (3,093 males and 131 females), fit our inclusion parameters for relevance that included either the most identifiable presentation of FG or the most effective treatment. From our search, the most common clinical presentation was scrotal and labial pain, fever, abscesses, crepitus, erythema, and cellulitis. Diagnosis is made from clinical findings in conjunction with imaging. The gold standard for treatment was found to be a combination of surgical debridement, broad-spectrum antibiotics, and the administration of intravenous fluids." (Lewis, G. D., Majeed, M., Olang, C. A., Patel, A., Gorantla, V. R., Davis, N., &amp; Gluschitz, S., 2021).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is not substantiated.