Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis (breast pain and redness)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with medical history of asthma and DM (diabetes mellitus). She was noncompliant with her medications for a long time. She presented to the ED (emergency department) with complaints of swelling and pus drainage from right breast.

The patient stated that she had a pimple to the right breast a week prior, and that she picked at it. A tender mass then developed, and it began expelling pus two days before her presentation to the ED (emergency department).  There is no history of trauma.

The patient denied fever, chills, diaphoresis, nipple discharge, light headedness, malaise, chest pain, nausea, vomiting or SOB (shortness of breath). The patient was started on treatment with IV (intravenous) fluids, IV (intravenous) antibiotics, and insulin. Consultation was obtained from surgery and infectious disease. The patient improved with treatment, and the patient was discharged home on oral antibiotics for outpatient follow up.

No, the Inpatient admission was not medically necessary.
Based on the available information, the patient could have been safely and effectively managed without inpatient hospital admission.

During this admission, the patient presented with complaints of swelling and pus discharge from the right breast. The patient denied fever, chills, diaphoresis, nipple discharge, light headedness, malaise, chest pain, nausea, vomiting or SOB (shortness of breath). The patient denied nausea or vomiting, and the patient was able to tolerate oral intake upon presentation and during hospital stay. Evaluation in the ER (emergency room) showed BP (blood pressure) 153/98, P (pulse) 102, T (temperature) 98 Fahrenheit, R (respiration rate) 18, Pulse oximetry 100%. The patient was afebrile and hemodynamically stable. Admission labs showed WBC (white blood count) 9.6; hemoglobin 13.6. Follow up labs during hospital stay continued to show acceptable WBC (white blood count) values (WBC [white blood count] values ranged from 8.8 to 10.4 during hospital stay). The patient had hyperglycemia and elevated HbA1c (glycated hemoglobin); however the patient was known to be noncompliant with diabetic medications. Additionally, the patient did not have any symptoms related to the hyperglycemia; the patient did not have acidosis and clinical evaluation / lab results did not show DKA (diabetic ketoacidosis).

Evaluation by the surgical team in the ER (emergency room) indicated no need for incision or drainage for the breast cellulitis - abscess. The patient had not been treated with and failed antibiotic in the outpatient to necessitate inpatient stay for treatment.

Continued inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk as based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent.

For the duration, the patient was afebrile and had stable vital signs. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered / work up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital. During the above duration, the patient's diagnosis had been established clinically and based on the results of the investigations. The patient was hemodynamically stable and afebrile.

For the above duration, the patient had stable vital signs and routine labs remained at baseline. The patient's temperature and other vital signs were not representative of sepsis during this time. The patient was able to eat food, drink fluids and take oral medications. Although patient had pain, it was not intractable, and not noted to be amenable to appropriate oral treatment. Care rendered during this time was of low intensity. No systemic findings such as high fever, shock, liver failure or abnormalities of mental status were noted during this time. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. The patient was not in acute distress and in view of these facts of the patient's clinical status, ongoing risk of deterioration was low since diagnosis had been established. The patient did not have any acute complications during this time. No high frequency, high complexity, or high risk procedures or interventions were necessary during this period of time.

Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates. In view of these findings, therefore, the ongoing inpatient level of care for the above duration was not medically necessary.