CLINICAL SUMMARY:
A 35-year-old patient arrived in the Emergency Department suffering from a painful abscess and swelling on the left buttock. The patient, whose medical history includes hidradenitis suppurativa, bipolar 1 disorder and asthma, described the pain as an excruciating stabbing sensation rated at a level 10. Furthermore, the patient reported shortness out of breath due to the pain. The patient appeared visibly uncomfortable. Vitals and labs upon admission were unremarkable, and were as follows: Tmax 99.1, HR 84, RR 16, BP 113/74, SpO2 100% RA, WBC 10.97, Hgb 12.4, Na 138, K 3.8, BUN 19, Cr 1.00, Glu 83, blood culture x 2: negative. Wound culture showed light growth of Schaalia turicensis (S. turicensis). On physical examination, there was a large area of induration over the right medial aspect of the buttock, with multiple areas of indentation of the skin. Additionally, on palpation the patient reported tenderness.
A CT scan showed extensive skin thickening and subcutaneous edema along the left gluteal fold, with several tubular structures within the subcutaneous soft tissues along the left gluteal cleft. Doctors determined the findings were compatible with Hidradenitis suppurativa with ongoing cellulitis of the left buttock. Surgery was consulted, however there was no drainable fluid to prompt an incision and drainage (I&D). It was noted that the patient had a history of I&D and the treating physician recommended observation admission for intravenous antibiotics and Dilaudid for pain medication.
On day two of the hospitalization, the case was referred to AppriseMD for a second-level physician review. After reviewing the patient’s medical chart, an AppriseMD physician advisor recommended changing the level of care (LOC) from observation to inpatient based on the ongoing IV medication being administered, which included ceftriaxone, metronidazole, Dilaudid, ondansetron and vancomycin. The physician advisor concluded that the patient would likely require hospital care beyond the observation period, supporting inpatient admission due to the increased intensity of care.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe patient’s Medicaid plan denied the inpatient admission. The payer cited that the cellulitis diagnosis was not accompanied by a weakened immune system nor imaging to support swelling with an infection around the eyes. Moreover, the payer specified that the cellulitis did not occur over a man-made body part or device inside the body. The denial stated this decision was based on InterQual guidelines for acute adult infection of cellulitis.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSAn AppriseMD physician advisor discussed the denial with the payer medical director during a peer-to-peer review. The physician advisor was successfully able to defend the second-level review determination which recommended an inpatient LOC admission, resulting in the denial being overturned. The discussion centered around several factors.
First, the patient was seen by infectious disease and treated with IV antibiotics. The inpatient admissions status initially was denied due to the lack of fever, leukocytosis, an immunocompromised state, and the fact that the patient was hemodynamically stable. The criteria for cellulitis are quite strict; however, the physician advisor reasoned the reversal based on pain management. He emphasized the fact that on hospital day three, the patient was still requiring intravenous Dilaudid. After this compelling discussion, which included a reminder that the patient received three doses of IV Dilaudid on this date, the payer medical director agreed with the AppriseMD physician advisor and approved the higher LOC.