Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Surgical infection
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is an adult patient with a history of right breast cancer and mastectomy. Per the emergency department (ED), the patient was 2 weeks post op from right breast implant surgery. The vital signs included a temperature of 100.3 degrees Fahrenheit, heart rate of 103 and a blood pressure of 125/77. The patient had a tissue expander removed and silicone implant placed in the right breast 4 weeks prior to presentation to the ED with right breast infection. The patient had the Jackson-Pratt (JP) drain removed in the clinic the day prior. The plan was to take the patient to the operating room for washout and possible implant exchange. The White Blood Count (WBC) was 8.5.

The patient underwent a right breast implant removal under general anesthesia with findings of an infected seroma overlying the breast implant which was evacuated. The right breast implant was removed, and a right JP drain was placed. The Post op (operative) check note indicated the patient was doing well with stable vital signs and was afebrile with the pain controlled. The patient tolerated the procedure well and went to the Post Anesthesia Care Unit. Once the patient was stabilized, the patient was transferred to the surgical floor and received intravenous (IV) antibiotics. With the pain controlled and being able to tolerate the diet the patient was discharged home on oral antibiotics.
	
MCG (Milliman Care Guidelines) Health Inpatient and Surgical care 26th edition Cellulitis ORG: M-70 (ISC), admission is indicated for 1 or more of the following: hemodynamic instability; altered mental status that is severe or persistent; Failure of outpatient therapy; Limb-threatening infection (possible neurovascular compromise, deep hand space infection); Clinical presentation (acuity of infection, rapidity of progression) is judged to require intensity of patient monitoring (vital sign measurement, checks for infection progression) that cannot be provided at other than inpatient level of care;  bacteremia; Suspected necrotizing soft tissue infection (gas in tissue); Severe oral or head and neck cellulitis (Ludwig angina); Surgical procedure needed (abscess drainage, debridement) that necessitates inpatient setting; Orbital infection; Preseptal or perineal infection that is severe or progressive; severe pain requiring acute inpatient management; Inability to maintain oral hydration (IV fluid support needed); and Compartment syndrome monitoring. MCG also notes that alternatives include: Outpatient care in the emergency department, rapid treatment site, urgent care center, or medical office; Laboratory and diagnostic testing; Oral or parenteral antibiotics; Pain management; Re-examination in 6 to 8 hours; and Outpatient follow-up. 

MCG Health General Recovery care 26th edition Wound and skin management notes that the Operative Status Criteria includes Ambulatory with examples including: Most skin lesion surgery; Most incision and drainage of skin or tissue; Most elective skin grafting; Partial-thickness burn care for less than 10% of body surface area if not involving hands, feet, face, perineum, genitalia, or major joints. 

Based on the above, this procedure could have been done in ambulatory/observation setting as the patient did not need an acute inpatient admission. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.