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

The patient is a male child born prematurely at 35 weeks' gestation that was referred to the emergency department (ED) by the pediatrician for evaluation of a perirectal abscess. He presented with two-day history of fever, vomiting, and diarrhea. In the pediatrician's office, a swelling was noted, prompting referral to the emergency department. He continued to have loose watery stool and decreased urine output.

Vital signs included temperature 37, heart rate 151, and respiratory rate 30. Examination was significant for no distress, moist mucous membranes, benign abdomen, good capillary refill, swelling in the perirectal region at 1200 with erythema extending to the perineum and edge of the scrotal sac, mild fluctuance and induration measuring three by two centimeters, and non-focal neurologic exam. Laboratory evaluation revealed leukocytosis with white blood cell (WBC) count 15.09 thousand (K). Ultrasound was significant for a large complex collection measuring 2.4 by 2.2 by 1.6 centimeters with internal swelling, debris, and peripheral hyperemia, compatible with a perirectal abscess measuring up to 2.4 centimeters.

The patient was treated with intravenous (IV) fluids and a General Surgery consultation was requested. He started treatment with Zosyn and was taken to the operating room (OR) for incision and drainage, with eight milliliter (mL) purulent fluid recovered. The patient tolerated the procedure well. The following day, half of the packing was removed. Pain was well-controlled, and he remained on Zosyn pending culture results. Cultures returned positive for pan-sensitive E. coli (Escherichia coli). He was deemed stable for discharge after the remainder of the packing was removed to complete a course of therapy with Augmentin

No, the proposed inpatient admission was not medically necessary.

Perianal abscess is a relatively common problem with some controversy associated with management. Conservative management has been favored over surgical management because of less recurrence and lower fistula formation rate. However, in certain circumstances (systemic symptoms, significant discomfort), surgical intervention is necessary. Antibiotics may be prescribed in the office or in the hospital.

In the case of this young infant with an acute diarrheal illness, he had signs of systemic illness with fever. Ultrasound revealed a complex lesion measuring 2.4 centimeters that the surgeon felt required incision and drainage in conjunction with parenteral antibiotic therapy. While it was reasonable and appropriate to monitor him prior to and immediately after surgical drainage for response to therapy, he was overall hemodynamically stable with no evidence of impending sepsis and no significant underlying chronic illnesses to complicate his recovery. He did not require acute inpatient admission and could have been safely managed at a lower level of care in the hospital such as observation.