202112-144174
2022
Healthfirst Inc.
Medicaid
Skin Disorders
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Recurrent Thigh Abscess
Treatment: inpatient level of care
The insurer denied coverage for inpatient level of care
The denial is upheld.
The patient has a past medical history significant for recurrent thigh abscess who was referred to the emergency department with complaints of worsening pain in her right posterior thigh.
Her vital signs on presentation included: temperature 98.2, blood pressure 106/72, pulse 87, respiratory rate 20, and oxygen (O2) saturations 100% (percent) on room air. Laboratory results included the following: white blood cell count (WBC) 7.7, hemoglobin (HGB) 10.8, hematocrit (HCT) 33.9, creatinine 0.83 and glucose 99. The patient was admitted for evaluation of a recurrent thigh abscess. She underwent an incision and drainage procedure by surgery. The patient tolerated procedure well; she remained afebrile and hemodynamically stable. The patient was discharged on oral antibiotics (Augmentin) to continue outpatient management.
According to documentation, the patient was referred to the emergency room for a recurrent thigh abscess. Otherwise, she was afebrile and hemodynamically stable; laboratory results were unremarkable including a normal WBC. The patient did not have any evidence of a disseminated infection and she underwent an incision and drainage procedure. Based on above findings, the patient met criteria for an observation level of care.
The health plan acted reasonably with sound medical judgment and in the best interest of the patient.
The insurer's denial of coverage for the inpatient level of care is upheld. Medical necessity is not substantiated.