Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute paronychia infection
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male teen with unremarkable medical history that presented to the ED (emergency department) with two-day history of worsening left arm pain, swelling of the third finger, and streaking up the dorsal forearm into the left axilla with associated tender lymphadenopathy. Pain was 7/10 at its worst, with no relief from Tylenol. Vital signs included temperature 98.6, heart rate 96, respiratory rate 20, and blood pressure 95/65. He was treated with Tylenol and Unasyn prior to admission for management of lymphangitis. On admission exam, he was noted to have left axillary tender (3/10) lymphadenopathy, swelling of the left third finger with an erythematous streak and tender papular lesion tracking up the dorsal aspect of the hand and forearm to the axilla. Laboratory evaluation revealed leukocytosis (12.1K) with left shift (68% neutrophils). Metabolic panel was unremarkable. Admission orders included vital signs per unit protocol and parenteral clindamycin every eight hours. According to the admission note, sepsis was not considered, and the protocol was not initiated. By the next day, his left arm and hand had significantly improved with no erythema and decreased swelling. He denied pain. His left arm was still mildly swollen with no tenderness to palpation. He was deemed stable for discharge to complete a seven-day course of clindamycin.

No, acute inpatient treatment was not medically necessary.
Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient. 

Lymphangitis is an infection of the lymphatic channels. It is usually caused by an acute bacterial infection, but may also be caused by parasites, mycobacteria, and malignancy. It is generally rapidly progressive and may be associated with systemic symptoms such as fever and malaise. It characteristically presents as streaking with proximal lymphadenopathy. Treatment includes antimicrobial agents with possible surgical intervention. 

This male teen presented with acute paronychia infection complicated by acute lymphangitis. Other than pain, erythema, and swelling, he had no systemic symptoms. He had not been treated in the outpatient setting. While it was reasonable to initiate treatment in the hospital because of the rapidly progressive nature of this infection, he was overall hemodynamically stable with no evidence of sepsis, no need for parenteral pain medications, and no evidence of compartment syndrome. He did not require acute inpatient admission and could have been safely managed at a lower level of care.

Yes, the health plan acted reasonably.