Abscess: when insurers say no, reviewers often say yes

Where the denial was overturned

A 51-year-old male enrollee requested emergency services for medical treatment of anal pain. Findings: The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented with severe anal pain, which was refractory to therapy. He reported his pain level at 10/10 and was provided a dose of morphine for pain control. In addition, the patient had concern for a possible infectious etiology. A prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy. All told, the patient’s symptoms would lead a prudent layperson to believe their health to be in imminent danger.

A 35-year-old male enrollee has requested for emergency services for treatment of his buttock abscess. Findings: The physician reviewer found that the patient’s symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a large buttock abscess with 10/10 pain would reasonably expect the absence of emergency care to jeopardize their health. The patient’s pain level and the fact that the abscess required operative excisional debridement support the need for immediate care. Infected dermatological abscesses are normally incised and drained in the ED under local anesthesia and only go to the operating room if complex.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laser hair removal. Treatment of pilonidal sinuses can be challenging as there are multiple modalities and options with varying rates of success and support in the current medical literature. The American Society of Colon and Rectal Surgeons’ clinical practice guidelines for the management of pilonidal disease provide a comprehensive summary of many treatment modalities for pilonidal sinuses. In particular, elimination of hair from the gluteal cleft and surrounding skin by shaving or laser removal is given a weak recommendation based on low quality evidence, and the guidelines do not include evidence that one modality, laser removal, is better than the other, shaving.

The enrollee’s parent is requesting authorization and coverage for laser hair removal for a history of pilonidal disease, status post incision and drainage. The records indicate the enrollee underwent a procedure of incision and drainage (I&D) for an eight centimeter abscess, and an antibiotic course of Ancef. A follow up visit indicated the wound was closed and education was provided including possibility of elective pilonidal cyst excision in the future, good hygiene and hair removal with waxing, Nair or laser hair removal. Follow up at the surgery clinic indicated drainage from the incision site was clear but a 10 day course of antibiotic was prescribed for prophylaxis, and aggressive hygiene and hair removal was advised. At a subsequent follow-up visit, there was no longer any drainage or pain at the incision site and instructions were to return to the clinic as needed.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for abscess was denied, the published record says the denial is worth fighting.