Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Laceration to the left third digit

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld

This case involves a 1-year-old female who presented to the emergency department on after a complex laceration to her distal phalanx of the left third digit sustained from a bite from a pet guinea pig. The patient was admitted and underwent wound exploration and complex laceration repair in the operating room under general anesthesia.  Postoperatively, she received 1 dose of Augmentin orally along with intravenous Unasyn 50 mg (milligrams) per kilogram every 6 hours for the prevention of infection and a loss of function of the digit. She was subsequently discharged home with oral antibiotics.  Records stated that the patient was denied coverage for the inpatient admission. The reason for denial of coverage was that the patient presented to the hospital with a cut on her finger that required surgical repair. The procedure was completed without complication and there was no need for a hospital admission. An appeal was submitted on indicating that the patient required prompt surgical management with wound and laceration repair to be performed under general anesthesia. Postoperatively, the patient required close inpatient monitoring with intravenous antibiotics, wound care with silver sulfadiazine, and a series of examinations to prevent wound dehiscence, bleeding, secondary infection, uncontrolled pain, and permanent functional impairment. 

The health care plan acted reasonably and with a sound medical judgment and in the best interest of the patient. The evidence noted that based upon the provided documentation, the patient's care could have been rendered on an observational or outpatient basis. She did not require the inpatient level of care throughout the timeframe in question.

Literature states that most animal bite wounds are polymicrobial in nature. Infected bite wounds manifest with swelling, erythema, and tenderness with or without drainage of the affected site and can lead to serious complications. Basic medical management of by wounds includes thorough cleansing and debridement along with irrigation, closure, need to obtain culture depending on the type of the bite wound, the appearance of the wound, and the timing of medical evaluation after the initial injury. The Milliman Care Guidelines provide indications for inpatient care for patients who have wound complications. However, the patient was not found to meet the criteria for inpatient care and could have been treated on an observational or outpatient basis. She underwent surgery without complication and recovered well postoperatively. Based upon the provided information, the inpatient stay was not a medical necessity as the patient could have been treated on a lower level of service. As such, the inpatient admission for the dates of service were not considered medically necessary for this patient. The prior determination is upheld. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.