Appeal type: Medical necessity
Decision: Overturned in Part

The patient is a female with Sjogren's, irritable bowel syndrome (IBS), and systemic lupus erythematosus (SLE). She presented to the emergency department (ED) status/post (s/p) a bilateral breast implant exchange 1 month prior to admission with bilateral breast wounds and extreme tenderness. The patient initially had a breast augmentation. She was dissatisfied with the appearance and volume and decided to reduce her implant size. She underwent implant exchange from 420 cubic centimeter (cc) to 320 cc per patient via bilateral inframammary (IMF) incision. The patient also stated that her surgeon additionally "tightened" her breast skin" however she was unable to describe in more detail what she meant. Immediately after the surgery she noticed blistering bilaterally. She was seen by her surgeon and started on a course of Ciprofloxacin with local wound care. Over the next days, she developed partial skin necrosis with epidermolysis and 5 x 8-centimeter (cm) area of full thickness necrosis over the left breast. She reported one episode of fever at home prompting her to present to the ED.
In ED the patient had exquisite tenderness but was afebrile. She denied having any discharge. She also reported nausea but no vomiting. Her white blood cell (WBC) count was 34. On exam her chest was tender to palpation over both breasts, right breast had multiple areas of partial skin necrosis and epidermolysis with intact underlying dermis; left breast had a 5 x 8 cm area of full thickness skin necrosis with some drainage, left NAC with partial necrosis, no redness. Computed tomography (CT) scan of the-chest showed hyper attenuation and fat stranding surrounding bilateral breast implants, left greater than right with diffuse skin thickening of the bilateral breasts, suggesting cellulitis/mastitis superimposed-on postsurgical changes. The patient was started on Vancomycin IV and Zosyn IV. She received IV antibiotics for 72 hours and then had surgery to remove the implants bilaterally, and irrigation and debridement of the left breast wound. The left implant pocket was entered and approximately 100 milliliter (mL) of turbid fluid emanated. Aerobic, anaerobic, fungal, and acid-fast bacilli (AFB) cultures were sent. An identical procedure was performed on the right side, with the same cultures taken. This fluid measured approximately 50 mL. The nonviable tissue and skin on the left breast was sharply debrided with a #15 scalpel. Jackson-Pratt (JP) drains were placed to self-suction in both breasts. IV antibiotics were continued postoperatively as well as wet to dry dressings. Cultures from the operating room (OR) grew Klebsiella pneumonia and the patient was refusing IV antibiotics. Infectious disease (ID) recommended Augmentin. Levofloxacin by mouth (PO) and Flagyl PO were started per ID. Her leukocytosis continued to uptrend despite antibiotics, no other clear source. The patient was vomiting and not keeping down PO antibiotics. The patient's pain was poorly controlled. Her pain medication and antibiotics were switched to the IV route. Pain control was slightly improved with IV medication, she still had some nausea and emesis and mild abdominal discomfort, with ongoing loose watery stool. She remained on IV medications. Zofran IV was started. Wet-to-dry dressings with sulfadiazine were changed to enzymatic debridement. The drains were removed. The patient had increased abdominal pain and refused CT scan. She remained on IV medications until she was discharged.

The health plan's determination is overturned, in part.

Admission and inpatient care was medically necessary, in part.
The patient had a breast infection secondary to her breast implant. Her WBC was 34, extremely elevated. She was at high risk for developing sepsis until the implant was removed. She was treated with IV antibiotics but required monitoring of her wounds and her hemodynamic status until her infection had resolved or her implant was removed.  Managing her condition at a lower level of care would not have been safe because of her high risk of developing sepsis due to the infected prosthesis. Her course confirms that admission was required. Her infection did not improve, and implant removal was required. Her infection was slow to respond to removal of the implants and antibiotics. She developed renal insufficiency requiring fluid resuscitation. Her WBC count continued to rise, and she developed nausea. Her drains were removed, and enzymatic debridement of her wound was started. Her creatinine was improving, her pain was controlled, and she was tolerating oral intake. Inpatient admission was not required for the full stay because the patient was improving.