Diagnosis: Fever, chills, and buttocks pain
Treatment: Inpatient Hospital Admission
The insurer denied coverage for Inpatient Hospital Admission.
The denial is overturned.

Patient is an adult female with past medical history significant for morbid obesity, status post bypass surgery, and recent adipose tissue transplant of her buttocks who presented to the emergency department with complaints of fever, chills, and buttocks pain.

Vitals on presentation included: Temperature 100.8 degrees Fahrenheit, Blood Pressure 132/99, Pulse 160, Respiratory Rate 23, oxygen (O2) saturation 98% (percent) on Room Air. Laboratory results included the following: white blood cell (WBC) count 9.3, hemoglobin 5.9, hematocrit 19.1, creatinine 0.6, glucose 94. Chest x-ray (CXR) showed extensive areas of subcutaneous emphysema within the chest wall bilaterally, concerning for necrotizing fasciitis.

Patient was started empirically on intravenous antibiotics (vancomycin, Zosyn, and clindamycin) for possible post-operative necrotizing fasciitis. Urinalysis was suggestive of a urinary tract infection (UTI). Patient was transfused 2 units of packed red blood cells (PRBC). Surgery recommended continuation of antibiotics; no surgical intervention was deemed necessary. Patient remained afebrile, clinically, and hemodynamically stable. She was discharged to continue outpatient management.

According to documentation, patient presented with multiple medical issues. Patient was febrile (100.8 F (Fahrenheit)), tachycardic (heart rate 160), and tachypneic (respiratory rate 23). Laboratory results were notable for several abnormalities including severe anemia (hemoglobin 5.9). Imaging studies, also abnormalities suggestive of infection. Based on above findings, in a high-risk patient who underwent a recent surgical procedure, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is substantiated.