Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This case involves a patent who presented to the emergency department complaining of 10/10 pain to the right groin/pelvis and endorsed having a drain malfunction from a draining seroma.  The patient claimed that they were seen before for the same issue and was able to unclog the drain and flush it.  However, the patient began to feel pain and pressure in the suprapubic region and tried to flush the drain without success.  The patient reported feeling full, with a constant ache and returned to the emergency department at that time.  On assessment, the patient's vital signs were stable except for an elevated heart rate at 135.  The patient's body mass index was elevated at 32.5.  The report stated the patient had a past medical history involving an abdominoplasty complicated by abdominal seroma that required recurrent drainage with interventional radiology (IR) that was last upsized the day prior.  The patient presented with worsening pain, subjective swelling, and decreased drainage from the drain.  The patient denied fever, chills, dysuria, constipation, rash, discharge at the site, or other complaints.  On assessment of the abdomen, the patient had mild tenderness to palpation in the right lower quadrant.  The drain and dressing were clean, dry, and intact with no peri-drain discharge noted.  There was mild erythema directly adjacent but not obviously cellulitis.  There was palpable fluctuance deep to the drainage, which may be seroma.  Treatment for sepsis was not indicated but the patient was expected to require at least 2 days of inpatient care.  The patient was subsequently admitted for further work-up and treatment of the seroma.  The patient had a residual seroma collection present with additional testing negative for any signs or symptoms of infection.  The patient was subsequently discharged in stable condition.  The patient received a notice that the inpatient admission was denied coverage.  The claim was that this care could have been rendered on an observational basis with an ambulatory plan of care.  An appeal was submitted stating that the patient had severe abdominal pain, flank pain, swelling to the right groin and pelvis with malfunction and decreased output from the abdominal drain.  The patient had an emergent drain exchange by interventional radiology.  

The Milliman Care Guidelines state that inpatient care for those individuals with wound and skin care complications or conditions may be clinically indicated when there is significant infection, hematoma, when the individual has sustained a significant burn or when a procedure treatment is required such as drainage of infected material, dehiscence requiring frequent monitoring or immediate treatment, evacuation of a hematoma, percutaneous placement of close suction drains with pressure dressing, or the need for wound treatment that cannot be performed at lower level of care.  While it was noted that the patient had an abdominal seroma with a drain in place, it was determined that the area was not infected and that the drain replacement could be completed on an outpatient or observational basis.  The patient did not have any factors that place them at increased risk requiring an inpatient level of care.  Given the provided information, the inpatient admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.