Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal cancer. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She was initially diagnosed with rectal cancer. Following a course of neoadjuvant radiation, she underwent a low anterior resection. She initially did well, but developed a local recurrence and subsequently underwent a robotic assisted abdominal perineal resection. 

The patient presented to urgent care with complaints of fever of three days duration. She denied nausea, vomiting and abdominal pain. She did note drainage from the site of a JP (Jackson Pratt) drain, which had been removed. Her temperature was 101.7, and her WBC (white blood count) was 11,800. A CT (computed tomography) scan showed a fluid collection in the pelvis. She was started on IV (intravenous) antibiotics and admitted to the hospital for further management. Comorbidities include hypertension, type II diabetes, sleep apnea and congestive heart failure. 

The patient's Hospital Laboratory studies document the following: A urine culture was positive for Pseudomonas and Enterococcus. Cultures obtained from the infected hematoma were identical. All Blood cultures were reported as negative. Serial WBC (white blood counts) were obtained and showed counts of 10,880 on day 2, 11,400 on day 3, 10,300 on day 4, 9,300 on day 5, and 9,400 on day 6. 

The Health Plan has denied the admission as not medically necessary, noting that the severity of the patient's problems did not meet the level required by MCG (Milliman Care Guidelines) for acute inpatient care and could have been managed without a full admission. 

The hospital appealed noting that the patient was a cancer patient, was placed on IV (intravenous) antibiotics, required frequent monitoring of blood glucose levels with insulin adjustment and required placement of a drainage catheter to evacuate the pelvic collection. 

No, the Inpatient admission was not medically necessary. 

A review of the submitted medical records reflect that the patient had developed an infected pelvic hematoma following her abdominal perineal resection. This was most likely due to enteric bacterial contamination of the surgical field. It also resulted in a urinary tract infection, as cultures of both the hematoma and urine had identical results. 

When the patient presented to urgent care, she exhibited a mild elevation of her temperature and an elevated white blood cell count. A CT (computed tomography) scan was confirmatory of a pelvic collection, and International Radiology placed a per-cutaneous drainage catheter the following day. 

Throughout her hospital stay, the patient remained afebrile, with her temperature and her white blood cell count never exceeding that which was evidenced in urgent care. Her vital signs were stable. Her abdominal exam was benign. Her appetite was poor, but her stoma continued to function. Her Type II diabetes was managed with sliding scale coverage. 

The Infectious Disease Consultant recommended a 14 day course of antibiotics following drainage with conversion to oral agents at time of discharge. He did not recommend continuance of IV (intravenous) antibiotic therapy beyond her discharge. 

The patient exhibited no signs of sepsis or systemic infection during her stay. 

Neither the severity of the patient's illness nor the services rendered following admission rose to the level of acute in-patient care. The patient's care could have been rendered effectively and safely at a lower level of care. The Inpatient admission was, therefore, not medically necessary.