Diagnosis: Skin Disorders.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The denial is upheld.

The patient is a male with a history of diabetes and COVID. Late in the evening he presented to the emergency room for worsening pain, swelling, redness, and discharge from his posterior neck. He was seen one day previously and was prescribed an antibiotic ointment and oral antibiotics. On exam, he was well-appearing and was afebrile. Skin exam revealed pustules on the posterior neck with associated swelling, erythema, and tenderness. Labs were notable for a white blood cell (WBC) count of 11,400, glucose 323 milligrams per deciliter (mg/dl), and a urine glucose of greater than (>)10000 mg/dl. A computed tomography (CT) scan of the neck revealed subcutaneous inflammatory changes but no clear collection to suggest an abscess. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The pustules were "drained manually". The patient was admitted for further treatment and evaluation.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. He was afebrile, and there was no hemodynamic instability, mental status changes, or severe metabolic disarray. The diagnosis was not clinically challenging, and the treatment was straightforward. The services provided - intravenous antibiotics and consultations - did not require acute inpatient admission. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.