Diagnosis: cancer
Treatment: inpatient hospital.
The insurer denied inpatient admission.
The denial is upheld in whole.

The patient is a female who presented to the emergency department (ED) for evaluation of complete wound dehiscence of her right breast with exposure of the breast implant. Her history is significant for breast cancer treated with mastectomy, chemotherapy and radiation, and an eventual breast reconstruction. Her treatment was complicated by chemotherapy induced cardiomyopathy with a significantly decreased ejection fraction (EF) of 30%.
She was admitted to the surgical service for definitive treatment. She was started on intravenous (IV) antibiotic Cefazolin every 8 hours. She required Cardiology clearance prior to surgical intervention, and although she was found to be at increased risk, she was cleared for surgery. She also was hypokalemic and received IV potassium chloride (KCL) x 3 doses. The operative procedure was performed with the implant removal, irrigation of the wound and Jackson-Pratt (JP) drain placement. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The patient presented to the hospital with an exposed breast implant. Per the notes, she was not sick, and her wounds were not infected. Exam showed no pus or erythema in the wound. Cardiology clearance was completed. Potassium replacement was accomplished. Surgery was performed to remove the expander and wash out the wound. The patient had an uneventful postoperative course and was discharged.
She had an exposed breast implant that was not clinically infected. She was not septic. She required preoperative clearance from cardiology and potassium replacement. Both were accomplished. She could have been managed at a lower level of care status. This patient was medically stable. Consultation and potassium replacement were accomplished within 24 hours of presentation. Her breast procedure is generally performed at a lower level of care. She could have been safely managed at a lower level of care status.