Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

This case involves a patient who presented to the emergency department complaining of chest pain and shortness of breath from the day prior.  The patient had bilateral breast reduction surgery in the Dominican Republic earlier that month and an electrocardiogram (EKG) was completed in triage.  Blood work orders were initiated along with diagnostic studies.  The patient localizes pain to the midsternal area noting that symptoms worsened with inspiration.  The patient claimed to have chills for 5 days but reported no fevers and denied leg swelling.  The patient reported abdominal pain, nausea, vomiting, and diarrhea for 2 days, but this had since resolved aside from a mild abdominal pain. The patient had retained sutures in the skin that had not yet absorbed. The patient's vital signs were stable. The patient was not in acute distress. The examination noted that the surgical incisions were clean, dry, and intact. There was mild erythema with blanching under both breasts on the right greater than the left with significant swelling that had improved per patient report. The patient had a healing surgical incision to the lower abdomen without evidence of infection. The patient had no significant tenderness palpation but there was significant induration noted.  Further findings included tenderness present in the left lower leg.  Laboratory testing was ordered along with EKG, computed tomography (CT) of the chest/abdomen/pelvis to rule out pulmonary embolism, and pain control.  The CT was without pulmonary embolism and plastic surgery was recommending fluids and antibiotics with a pending note for admission decision.  The patient was subsequently admitted for further work-up/care before discharge.  

The patient endorsed drainage from the breast incisions along with back pain and chills but no fever.  On the presenting physical examination, the patient's breathing was unlabored on room air.  The lateral skin flaps were with blanching and erythema bilaterally but no drainage from the incisions.  A low transverse incision was well-healed with peri-incisional erythema extending to the flanks bilaterally.  The abdomen was soft, nondistended, nontender, with no drainage and no palpable collection.  The abdominal wall had an area of skin burn and back was mildly tender but had no erythema and no obvious palpable collection.  The principal diagnosis was wound infection.  

In the case of this patient, 2 days of inpatient stay would be reasonable to address the initial needs given that the patient was presenting with some signs of infection.  While the patient was not febrile, they did have recent surgery and showed other early signs of cellulitis with imaging evidence of possible abscess or seroma along with erythema, and induration.  The patient did not require the full length of inpatient stay given that they responded favorably to the initial intravenous antibiotic regimen.  The records clearly stated that by day 2, the patient was ready for discharge on oral antibiotics.  After a review of the provided information, inpatient admission was only supported for two days.  As such, the request is partially medically necessary for inpatient admission for the first two days. Uphold denial of the remaining two days.

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is partially substantiated. The request is partially medically necessary for inpatient admission. Uphold denial of the last two days of the admission.