Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Inpatient hospital. 
The insurer denied inpatient hospital admission for medical necessity.  
The denial was upheld.
This is a male with a history of right knee pain with an area of progressive redness and swelling since the night prior to presentation. He also presented with a history of fever, 102.2 on day of presentation with some limited movements and limping. Father states he may have been playing with his friends a few days prior and had knee trauma. He also had insect bites to his lower extremity and had been itching with a recent bite to his right knee. 2 weeks prior to presentation the patient had an upper respiratory infection (URI) and sore throat. He tested negative for strep, so no antibiotics were given. No history of skin infection or methicillin-resistant staphylococcus aureus (MRSA) in the family.
The patient was sent from his primary medical doctor (PMD)'s office to the emergency room (ER) as his knee was worsening and there was concern for possible infection with MRSA. In the ER, the patient was afebrile with a heart rate (HR) at 123, respiratory rate (RR) was 22, oxygen (O2) saturation was 100% on room air (RA). His exam was significant for limited range of motion to his right lower limb. There were no signs of trauma or infection. There was an area of erythema, swelling, tenderness and warmth over the right knee with punctum surrounded by an area of induration with no active discharge. The patient was unable to walk or bear weight on his right knee.
His labs obtained showed an unremarkable complete blood count (CBC) with a normal white blood cell (WBC) count of 11.8. His C-reactive protein (CRP) was elevated at 5.2, and erythrocyte sedimentation rate (ESR) was normal at 15. Blood cultures were drawn and pending. The patient was given one dose of Ketorolac for pain, a normal saline (NS) bolus and was started on Vancomycin and Oxacillin intravenous (IV).
The ER physician reassessed at the time of admission and reported patient was weight bearing and moving knee in flexion and extension. Cellulitis was expected at this time and less likely a septic joint. Upon admission Oxacillin was changed to Cefazolin. Admitting diagnosis was cellulitis. The patient was admitted for IV antibiotics and placed nothing by mouth (NPO) for potential imaging in the morning.
On the floor, he improved with IV Vancomycin and Cefazolin. He was assessed by pediatric surgery and the orthopedic team. The consultant's assessment and ultrasound (US) showed small locution of fluid likely blood and not pus. Fracture, septic joint and osteomyelitis were ruled out. The surgery team diagnosed cellulitis with no surgical intervention necessary. They recommended to continue antibiotics and consult Orthopedics for recommendations on management of swollen knee. Orthopedics stated no intervention was needed at that time, continue antibiotics, and follow up as outpatient in 1 week. The patient had been afebrile for more than 24 hours prior to discharge. He was instructed to follow-up (f/u) with Pediatric Orthopedic in 1 week and sent home with by mouth (PO) clindamycin.
At issue is the medical necessity for the inpatient level of care.
The health plan's determination of medical necessity is upheld in whole.
No, the requested health service/treatment of inpatient stay was not medically necessary for this patient.
This patient did not require an inpatient level of care. He presented with a history of 102.2 temperature and a warm, swollen knee and surrounding insect bites. His WBC and ESR were within normal limits with a modest elevation in CRP. The patient was able to tolerate PO and did not have clinically significant pain. He was not reported to be immunocompromised where there would be concern for progression of his infection. He did not have any findings of a drainable abscess that would require surgical intervention. Fracture, septic joint and osteomyelitis were ruled out. He was hemodynamically stable. He did not have vital signs to suggest bacteremia or sepsis. He never received a trial of oral antibiotic coverage for MRSA. He did not have a gait disturbance and had full range of motion (ROM) of his knee as reported by the ER physician in his notes at the time the decision was made to admit to the hospital. 
His condition at admission did not warrant higher intensity of services or highly technical or skilled care. He went on to have an uneventful course that quickly responded to IV antibiotics. He was discharged within 48 hours without incident. There was no indication at admission that he would need surgical intervention. The mainstay of his care was administration of IV antibiotics. His findings correlate with favorable outcome and expected improvement with appropriate antibiotic coverage.
Therefore, the requested health service/treatment of inpatient stay was not medically necessary for this patient.