Diagnosis: Perirectal pain, perirectal abscess
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department with severe perirectal pain. The patient had a past medical history of a hemorrhoidectomy and pilonidal cyst resection. He reported the pain was constant and felt like a spasm. His vital signs demonstrated hypertension, a low-grade temperature to 100.1 degrees Fahrenheit. The examination did not demonstrate anal fissures, hemorrhoids or abscesses. A computed tomography (CT) scan demonstrated some thickening of the rectal wall. The patient was hospitalized to undergo a rectal exam under anesthesia (EUA). The patient underwent the EUA which demonstrated a peri-rectal abscess. This was drained. There were no complications. The patient was discharged later that day. At issue is the medical necessity of an inpatient admission.
The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient had a clear need for a surgical procedure, but did not have a need for inpatient level of care. There is no physician documentation of the need for an inpatient level of monitoring, complex diagnostics, or treatments other than the surgery. There is no evidence of patient specific problems that would require an inpatient level of care to meet medical needs or to assure patient safety. There is no evidence of a complicating event that occurred before, during, or after the patient's care that would require inpatient level of care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.