Diagnosis: Infection
Treatment: Inpatient Hospital Admission
The health plan denied: Inpatient Hospital Admission
The determination is: Upheld

The patient is a female with past medical history of hyperlipidemia (HLD), coronary artery disease (CAD), cerebrovascular accident (CVA), and traumatic brain injury (TBI) after fall from bike status/post (s/p) hemicraniectomy with functional decline, sacral decubitus ulcer with osteomyelitis s/p debridement, communicating hydrocephalus s/p ventriculoperitoneal (VP) shunt, multiple explorations of right cranioplasty due to cerebrospinal fluid (CSF) leak and infection most recently with long hospital course for wound dehiscence and infection, s/p tracheostomy, percutaneous endoscopic gastrostomy (PEG) and diversion colostomy. She presented to the emergency department (ED) with purulent drainage from site from previous scalp flap for cranial coverage. Her husband noticed a thick white discharge from her right scalp flap site.
She was empirically started on vancomycin and meropenem per infectious disease (ID). She was treated with scalp flap revision with plastics and recovered well with no further drainage. Deep operating room (OR) cultures grew staphylococci (staph) epidermidis, enterococcus faecalis, and coagulase-negative staph. She was transitioned from intravenous (IV) vancomycin and meropenem to oral linezolid.
At issue is the medical necessity of the full hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of full hospital admission was not medically necessary for this patient. The patient presented to the hospital with an infected scalp flap. She had a work-up in the ED with scans, laboratory studies, and plastic and neurosurgery consultations. She was clinically stable and was not septic. She was treated with IV antibiotics until scalp flap revision surgery was performed. There is no clear rationale for why surgery was delayed for this patient with an infection. Regardless, the surgery was straightforward, and recovery could have been accomplished at an alternate level of care. She could have then received IV and oral antibiotics and physical therapy at an alternate level of care. She did not have any acute issues (sepsis, hemodynamic, central nervous system [CNS] or respiratory failure) that required inpatient care and monitoring.