Appeal type: Medical necessity
Decision: Upheld

Diagnosis: wound ulcerations
Treatment: Hospital Admission
The insurer denied: Hospital Admission
The denial is: Upheld.

The patient is a female with a past medical history significant for hypertension and chronic lymphedema who was seen by a wound care clinic in the past. She presented to the hospital according to the recommendation of her wound care center. On the day of admission, the patient went to the wound care center for dressing changes and was found to have maggots in her wound. The dressing was changed, and the patient was referred to the emergency department where she was started on Unasyn. There was lower extremity edema with ulcerations on the dorsum of the left foot around 4 centimeters (cm) in diameter with granulation tissue base. There was ulceration on the dorsum of her third toe on the left. Maggots were seen in those areas. There was also an ulcer above the medial malleolus of the left foot. The left distal pulses were palpable. The patient was admitted to the hospital where she was evaluated by surgical service.
Wound care was initiated. The appearance of the ulcers improved with no presence of maggots, pus, or erythema.
According to the discharging physician, her lower extremities were nontender and healing well throughout the hospital course. The patient was discharged from the hospital, with an Unna boot.
The discharging physician stated that there were no signs of active infection, including no fever or elevated white blood cell count. At the time of discharge, the patient was recommended to follow up with the wound care clinic in a few days.

The health plan's determination is upheld.

The hospital admission was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital due to larval infestation, maggots, a condition in which fly larvae feed off and develop in the tissues of living organisms. Infestation associated with wounds is referred to as facultative or traumatic myiasis, in which flies opportunistically take advantage of necrotic conditions or infection to incubate their larvae.
Species that can cause wound myiasis include those from the Calliphoridae, Sarcophagidae, and Phoridae families. Most species are not pathogenic, and some are used in larval therapy as means to provide biological debridement.
In some cases, the patient is not aware of the infestation due to the location of the wound but may complain of itching or may sense movement in the wound. Wound myiasis is self-limiting and generally not harmful, but the presence of the larvae can be alarming to the patient, which is sufficient reason to remove them.
Removal involves irrigation to dislodge larvae that are not well attached. A simple removal of attached larvae is hampered by larval spines and hooks. Surgical debridement of surrounding tissue and the larvae together can usually be accomplished with local anesthesia. Care must be taken to avoid larval fragmentation, which can produce subsequent inflammation, bacterial infection, or granuloma formation.
In this particular case, there was no clear evidence that the patient had cellulitis, a soft tissue infection. The patient was afebrile, hemodynamically stable, and had a normal white blood cell count. This patient did not require wound care that necessitated an inpatient level of care.
Overall, the patient could have been managed at a lower level of care status.