Diagnosis: Hematoma
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a woman who presented to the hospital with pain and swelling of the right lateral thigh for the past 10 days and stated that she recently underwent abdominal liposuction and gluteal implants. At that time, she noticed an increase in size, pain and swelling of the thigh and hip. She also reported nausea, headache, fever and chills. She denied chest pain and shortness of breath. On physical exam, heart was regular and breath sounds were normal. She had a 15 centimeter (cm) x 7 cm area of induration with tenderness to palpation in the right lateral/proximal thigh with overlying warmth. The surgical incision sites were healed without discharge. Vital signs showed temperature 36.6 Celsius, heart rate 81, and blood pressure 111/71. Labs showed white blood cell count (WBC) 10.37, hemoglobin 10.0, platelets 496, sodium 139, potassium 3.9, and creatinine 0.59. Computed tomography (CT) imaging demonstrated hematoma versus abscess in the right thigh region. The patient was admitted for thigh abscess and iron deficiency anemia.

The inpatient hospital admission was not medically necessary. The patient was hemodynamically stable, had no fever, tachycardia or elevated white blood cell count, and had no acutely concerning findings on imaging beyond the presence of hematoma versus possible abscess. CT imaging was done at the time of presentation and when reviewed by the interventional radiology, their assessment was that there was no drainable collection. Overall, it was thought that the collection was more likely a hematoma rather than an abscess. For this reason, she could have been managed safely and effectively at a lower level of care.