Diagnosis: Vaginal abscess.
Treatment: Inpatient stay.

The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female with a past medical history significant for recurrent abscesses who presented to the emergency department with complaints of abscess in the left groin that extended to the vagina. Her symptoms had been going on for one week. The patient stated that she used to get abscesses in the past. Due to the abscess, the patient was unable to walk or wear her underwear. At the same time, she denied fever, chills, chest pain, shortness of breath, palpitations, cough, sore throat, nausea, vomiting, or any other symptoms.

The inpatient hospital admission was not medically necessary. In general, admission at the acute inpatient level of care is indicated for patients with cellulitis or soft tissue infection such as abscess when patients need a surgical procedure not amenable to the outpatient, emergency department, or observation care treatment. In this clinical case, the patient had a large abscess that was not amenable for outpatient or emergency department care.
However, considering overall clinical stability, the care could have been provided at a lower level. There was no evidence that the patient was immunocompromised or hemodynamically unstable. There was no mention of outpatient therapy failure. There were no indications that the patient had high-risk comorbid conditions necessitating admission to the hospital. The postoperative period was unremarkable. There was no indication that the patient's pain was so severe that she required admission at the acute inpatient level of care.