Diagnosis: Perianal abscess

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a male with past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, and asthma who presented to the emergency department with complaints of rectal pain. Vitals on presentation included: temperature 100.3 F, blood pressure 154/94, pulse 102, respiratory rate18, oxygen saturation 96% on room air. Laboratory results included the following; WBC-14.5, HGB-13.7, HCT-37.4, creatinine-1.4, glucose-684, sodium-125. The patient was started empirically on intravenous antibiotics (clindamycin and aztreonam) for possible perianal abscess. Surgery consulted and recommended imaging studies. CT scan of the pelvis showed a 2.5 cm perianal abscess. Colorectal surgery evaluated patient for a possible incision and drainage procedure. He continued to require insulin coverage and blood glucose monitoring. The patient remained uncooperative during his hospital course. He signed out against medical advice prior to completion of treatment.

According to documentation, patient presented with worsening rectal pain, fever (100.3 F), hypertension (154/94), tachycardia (102), and multiple laboratory abnormalities including elevated WBC (14.5), hyperglycemia (684), and creatinine (1.4). Moreover, patient had a perianal abscess that required surgical intervention. Based on above findings in a high-risk patient with poorly controlled diabetes, hospital admission was medical necessary for intravenous antibiotics and surgical evaluation.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is reversed.