Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intra-abdominal abscess
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the hospital emergency department (ED) with abdominal pain and intermittent fever. She has a past medical history of a known hepatic abscess. She was treated in the outpatient setting with antibiotics with a recurrent fever. At the time of presentation to the ED, her vital signs identified an elevated heart rate of 116 beats/minute. The white blood cell count (WBC) count was 10.6 thousand (K). Magnetic resonance imaging (MRI) (obtained during a prior admission) showed findings of a 5.8 x 4.3-centimeter (cm) thick walled enhancing lesion of or adjacent to the left lobe of the liver. She was admitted to the hospital.
A surgical consultation was obtained. The etiology of the intra-abdominal abscess was unknown. The patient underwent a diagnostic laparoscopy with drainage of a peritoneal abscess and drain placement. The patient was treated with post-surgical intravenous (IV) antibiotics. An infectious disease consultation was obtained. A cardiology consultation was obtained. She was further evaluated with an echocardiogram. The patient was without a fever and was still receiving IV antibiotics at this time. She was considered to be stable for discharge from the hospital with instructions for drain care and oral antibiotics for 6-weeks, and short term follow up.
At issue is the medical necessity of an inpatient stay.

Inpatient care was medically necessary for this patient.
The patient presented and was admitted to the hospital with an intra-abdominal abscess. This was in immediate proximity to the left lobe of the liver. The submitted records support that the patient was clinically stable at the time of presentation. However, she was having intermittent fevers at home in addition to abdominal pain. She had been previously evaluated and had a known mass versus (vs) abscess. She was receiving treatment in the outpatient setting with continued symptoms of pain and fever. Upon admission to the hospital, the patient was treated with surgical drainage of the fluid collection and drain placement. Pathology identified an abscess of idiopathic origin. She was treated with post-surgical antibiotics, infectious disease consultation, and cardiology consultation. The surgical drain was kept in place throughout the hospitalization. The care provided was reasonably anticipated to last more than 48 hours, required the coordinated care of multiple medical and surgical services, required surgery, post-surgical drain management and provision of IV antibiotics. The intensity of monitoring, the potential for rapid clinical deterioration given the patient's diagnostic test results and diagnosis of hepatic abscess, daily labs, need for prompt surgical treatment and provision of post-surgical antibiotics and drain management were consistent with an inpatient level of care. Additionally, this patient had had a failure of outpatient therapy with persistence / progression / no improvement after an adequate trial of an outpatient treatment regimen.
The care and treatment for this patient was most appropriate for an inpatient level of care.