Diagnosis: Abscess, Left Buttock.
Treatment acute inpatient level of care.
The insurer denied coverage for acute inpatient level of care.
The denial is overturned.

The is a patient with a past medical history significant for benign prostatic hyperplasia and hypertension who presented to the emergency department with complaints of progressively worsening pain in his left buttock. The patient underwent an incision and drainage while in emergency department (ED). Vitals on presentation included: Temperature 98.7 Fahrenheit, Blood Pressure 152/87, Pulse 107, Respiratory Rate 20, oxygen (O2) saturation 98% (percent) on Room Air. Laboratory values were notable for the following: white blood cell count (WBC)13.0, Hemoglobin-13.4, Hematocrit-40.8, creatinine-1.1, glucose-93.

The patient was empirically started on broad-spectrum intravenous antibiotics (ceftriaxone and metronidazole). Computed tomography scan showed fluid in the left gluteal fold (3.3 x 1.0 x 3.2 centimeters) compatible with phlegmon or developing abscess. Colorectal surgery evaluated the patient and deemed no surgical intervention was required. The patient remained afebrile, hemodynamically stable and clinically improved. He was discharged to continue oral antibiotics as an outpatient.

According to the documentation, the patient presented with worsening left buttock abscess despite treatment by his primary care provider with a course of oral antibiotics. The patient was afebrile, but tachycardic to 107 beats per minute. Laboratory results were notable for elevated WBC (13). Based on above findings, including documented failure of outpatient antibiotics, hospital admission was medically necessary for administration of intravenous antibiotics and surgical incision and drainage.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for acute inpatient level of care is overturned. Medical Necessity is substantiated.