Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bacterial throat infection.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a female child with medical history significant for eczema and facial burns that presented to the ED with one-week history of fever, cough, and chills, and two-day history of vomiting. She also reported bilateral ear pain.

The patient's vital signs included temperature 37.2, heart rate 120, respiratory rate 29 with 99% oxygen saturation in room air, and blood pressure 118/74. Examination was significant for no acute distress, mildly erythematous tympanic membranes bilaterally, nasal congestion, posterior pharyngeal erythema without exudate, healed facial burns, generalized eczema, tachycardia, and non-focal neurologic exam. Chest x-ray revealed mildly prominent peribronchial lung markings without consolidation or effusion. Laboratory evaluation was significant for mild hyperglycemia (glucose 119), normal troponin I, negative urinalysis, leukocytosis with WBC (white blood count) 22.2K and 67% neutrophils, thrombocytosis with platelets 520K, and positive rapid strep testing. 

The patient was admitted for management of clinical pneumonia and Streptococcal pharyngitis with persistent tachycardia. Prior to transfer to the floor, she received IV fluids and a dose of ceftriaxone. Admission orders included continued ceftriaxone with pending blood and urine cultures and IV fluids. On the second hospital day, her tachycardia resolved and her fever curve was improving. She was noted to have erythematous suppurative lesions on several fingers; wound culture and testing for HSV (herpes simplex virus) was obtained. Her antibiotic coverage was changed to clindamycin to treat potential MRSA (methicillin-resistant Staphylococcus aureus) infection. Repeat CBC (complete blood count) revealed improved WBC (white blood cell) count to 16.3K. Blood, urine, and throat cultures were all negative. She had no further episodes of emesis and no further fevers. 

The patient's symptoms had resolved sufficiently such that she was deemed stable to discharge home, with prescriptions for clindamycin to treat her impetigo and Elocon to treat her eczema. 

Impetigo is a bacterial infection of the upper layers of the skin, caused by either Streptococcus pyogenes or Staphylococcus aureus. Both bullous and non-bullous forms occur, with the bullous form generally occurring in neonates. Initially, vesicles and pustules develop that go on to form a thick yellow crust. Lesions spread quickly from autoinoculation. The face and extremities are most often affected. It is usually a self-limited infection, but can be treated with topical antibiotics to prevent complications and spread of infection. Eczema herpeticum is an herpetic infection arising from pre-existing skin disease, typically eczema or atopic dermatitis. Herpes simplex virus type 1 is the most common agent. This infection can be severe and even fatal. Bacterial superinfection may complicate the viral infection. In addition to the vesicular lesions associated with HSV-1 infection, there may also be constitutional symptoms such as fever and malaise. It is frequently confused with impetigo, because secondary staphylococcal infection may be present. Unfortunately, treating only for impetigo delays antiviral treatment of herpes. 

This young girl presented to the ED with signs and symptoms of an acute viral respiratory infection as well as eczema exacerbation and infection. Her physical examination was consistent with impetigo, but there was also possibility of herpetic infection, prompting HSV PCR (polymerase chain reaction) testing. She was initially febrile and tachycardic, with the tachycardia persisting after defervescence. There was concern for serious bacterial infection with cultures pending and initial treatment with ceftriaxone. Upon discovery of the skin lesions, her antibiotic was changed to clindamycin to cover possible MRSA infection. While it was reasonable and appropriate to monitor this child in the hospital for possible decompensation concurrent with initiation of treatment, she was overall hemodynamically stable with no evidence of sepsis other than tachycardia, no evidence of impending respiratory failure, and no significant dehydration. She did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.