Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a history of injection drug use who presented to the hospital with pain, swelling and a wound of the left hand. He had no other past medical history. He was a smoker and drank an unknown amount of alcohol with history of polysubstance use. On examination, vital signs were normal. The patient was not in distress. The left hand demonstrated a palmar ulcer, 3 centimeters across with fibrinous material in the base, but no notation of palpable bone or muscle was made. He also had smaller open areas in the third and fourth web spaces. He had undergone incision and drainage at an outside facility one week prior. No fluctuance or purulence was noted from the wound. No discharge was noted. The area was not noted to be violaceous, or to demonstrate any crepitus or blistering. The patient was administered intravenous (IV) vancomycin and Zosyn. Culture data was obtained from the outside facility and noted to show methicillin-resistant Staphylococcus aureus (MRSA). 

Orthopedics was consulted and recommended no further drainage, only intravenous (IV) antibiotics and warm soaks. The patient had a C-reactive protein (CRP) of 3.6 and erythrocyte sedimentation rate (ESR) of 58, but lactic acid and white cell count were normal. Temperature, heart rate and respiratory rate were normal. Anion gap, bicarbonate, kidney and liver function tests were normal. X-ray of the hand showed some gas possibly due to an open wound but no bone or joint abnormality. Zosyn was stopped once culture data were obtained. The patient signed out against medical advice. The physician taking care of the patient had noted that if there was clinical improvement, the patient would be discharged on oral Bactrim. 

No, the proposed acute inpatient admission was not medically necessary. 

Inpatient care is medically necessary when a patient's signs, symptoms, labs and imaging data demonstrate the need for intensive services not available in the outpatient setting based on assessment of the severity of the condition. Severe skin and skin structure infections have evidence of local and systemic inflammation or findings of local necrotizing infection or large abscess requiring operative drainage. The patient did not have violaceous discoloration, crepitus, fluctuance, blistering or gangrene at the site of infection. He did not have involvement of a large area of his extremity, with infection limited to the third finger and surrounding base of the palm. The physician documented normal pulse, capillary refill, color and movement/sensation of the hand and fingers. No fever was noted. White blood cell count was normal. Resting sustained tachycardia or tachypnea were not present. No hypotension was noted. There was no evidence of acute organ injury such as altered mental status, respiratory insufficiency, renal insufficiency, acute liver function test abnormality, acute coagulopathy or acute severe cytopenias to suggest sepsis. With lack of findings of local necrosis or fasciitis or large abscess, no anticipated need for surgery, and no palpable bone or joint as well as lack of systemic inflammatory response/sepsis, the patient's condition was amenable to oral antibiotic treatment in the outpatient setting after a period of observation on intravenous (IV) antibiotics. An observation level of care would have been appropriate to assess whether the patient had an adequate response to intravenous (IV) treatment for a period of up to 24 hours before making a decision to hospitalize the patient to inpatient status. In this case, there was considerable improvement within the first 12-24 hours and so an inpatient level of care was not medically necessary. 

The health plan followed the usual practice of judging a patient's risk and need for services based on the presenting clinical findings. These findings indicated a low risk condition not requiring intensive inpatient medical services. This is explained above.