Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with a history of injection drug use and use of cocaine as well as heroin who presented to the hospital from a detoxification center because of left upper extremity cellulitis and likely abscess. The patient had 10 to 15 centimeters of redness but ultrasound could not identify any window for drainage of the abscess. He did have a lump in that area. He also had right upper extremity cellulitis. This extended for eight to ten centimeters. The patient had chronic non-union of a tibia and fibula fracture of the left lower extremity with loose hardware. His white cell count was elevated. He had taken doxycycline and amoxicillin in the outpatient setting without improvement and had run out of antibiotics a few days before presenting to the emergency room.  He was also having symptoms of withdrawal from opiates. 

The patient was started on intravenous vancomycin and amoxicillin. He was admitted to the inpatient service for pain, opiate withdrawal and non-resolving cellulitis with abscess of the left upper extremity. His white cell count increased and he had a fever of 100.1 which prompted change of antibiotics to vancomycin, cefepime and Flagyl. With these measures the patient's cellulitis improved and white cell count also improved. He became afebrile. No surgical intervention was necessary. The patient was discharged on oral antibiotics and asked to follow up at a detoxification center or outpatient methadone program. The reason for denial is lack of medical necessity.

Yes, the proposed inpatient hospital admission was medically necessary.
The patient failed outpatient therapy for abscess of the left upper extremity and cellulitis that was extending 10 to 15 centimeters. Bedside drainage could not be performed in emergency room. The patient later developed fever and leukocytosis. He also had a history of opiate dependence and addiction. He was in withdrawal from opiates. There was a significant risk of relapse of infection and opiate withdrawal as well as further use of street heroin. This was a complex situation with high acuity and severity. Monitoring, laboratory studies, imaging and intravenous antibiotics were required for treatment. Consultation was obtained from addiction medicine as well as orthopedics. This involved multidisciplinary care and complex interventions which cannot be administered in the outpatient setting. Because of the high severity and multidisciplinary nature of the problem that the patient presented with, as well as frequent and complex interventions in the hospital, inpatient medical care was necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
For the reasons explained above, this patient required inpatient level of care for management of his medical condition. The plan denied inpatient medical care. In the absence of appropriate inpatient medical care there was a significant risk for relapse of street heroin use, withdrawal and progression of infection which had failed outpatient antibiotics. Therefore inpatient medical necessity was met. The plan denied inpatient medical necessity and therefore did not act in the best interest of the patient and use reasonable and sound medical judgment in making its determination.