Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abdominal wall abscess.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is partially overturned.

The patient is a female. She presented with an abdominal wall abscess. She had undergone diverting loop colostomy because of large bowel obstruction caused by a sigmoid mass. Her comorbidities included bilateral leg edema, for which the patient was on Lasix. Other relevant history is that the patient had multiple antibiotic allergies, including penicillin and metronidazole.

The patient's exam showed tachycardia and redness and tenderness in the right lower quadrant. CT (computed tomography) showed a 5-cm (centimeters) fluid collection. WBC (white blood cell) count was normal. Admission workup demonstrated a urinary tract infection (UTI). Cultures later showed E. (Escherichia) coli in the urine.

The patient underwent bedside I&D (incision and drainage) of the abscess. The abscess was thought to be caused by leakage from the colostomy. An infectious disease consultant was obtained to assist with antibiotic management. Gram stain and cultures demonstrated a polyfloral infection. The patient was treated with intravenous antibiotics and switched on the day of discharge to oral Bactrim.

The issue under review is the medical necessity of the inpatient hospital stay of three days duration. The patient was admitted and discharged. The entire stay was denied on the basis that the patient did not have any evidence of sepsis or serious medical condition, such as uncontrolled hyperglycemia, liver disease, or cardiac pathology.

The Inpatient admission was medically necessary, in part. Specifically, the inpatient admission for the first two days was medically necessary. Continued inpatient admission for the remaining dates was not medically necessary.

This female presented with an abdominal wall abscess. She had undergone diverting loop colostomy because of large bowel obstruction caused by a sigmoid mass. Her comorbidities included bilateral leg edema, for which the patient was on Lasix. Other relevant history is that the patient had multiple antibiotic allergies, including penicillin and metronidazole.

The patient's exam showed tachycardia and redness and tenderness in the right lower quadrant. CT (computed tomography) showed a 5-cm (centimeter) fluid collection. WBC (white blood cell) count was normal. Admission workup demonstrated a urinary tract infection (UTI). Cultures later showed E. (Escherichia) coli in the urine.

The patient underwent bedside I&D (incision and drainage) of the abscess. The abscess was thought to be caused by leakage from the colostomy. An infectious disease consultant was obtained to assist with antibiotic management. Gram stain and cultures demonstrated a polyfloral infection. The patient was treated with intravenous antibiotics and switched on the day of discharge to oral Bactrim.

The inpatient stay was partially medically necessary. This patient did not have a routine abscess that could be managed on an outpatient basis [1-2]. Instead, she had multiple factors requiring inpatient admission:

1)	She had possible leak from her colostomy, leading to formation of a large (5-cm [centimeter]) abdominal wall abscess. Inpatient stay is necessary to ensure that there is no ongoing leak from the colostomy and to confirm good response to the initial incision and drainage procedure.

2)	She had a polyfloral infection, including enteric bacteria. In addition, she had a UTI (urinary tract infection). On top of this, she had multiple antibiotic allergies. Selection of appropriate antibiotics is difficult in such patients. These factors no doubt were the reason an Infectious Disease consultation was obtained. The proper strategy in these cases is initial intravenous antibiotic therapy with later conversion to oral agents.

The above factors meant that initial hospital admission was medically necessary. However, the medical record does not demonstrate continued need for inpatient stay. The patient had exhibited 48 hours of stability following the drainage procedure. She had no evidence of sepsis, and the surgical site was improving. Considering this period of stability the risk of sepsis or ongoing leakage from the colostomy was low. The patient could have been safely discharged on oral antibiotics.

The previous denial decision did not take into account the complexities of this particular case. As noted earlier, the patient did not have a routine abscess that could be managed on an outpatient basis. However, after a period of stability, the patient could have been discharged one day earlier than her actual discharge.