Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Irrigation and debridement of right forefoot wound
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult female with a medical history significant for sleep apnea and asthma, dyslipidemia, and hypothyroidism. The patient has history of Morton's neuroma that was causing persistent symptoms for which she underwent three corticosteroid injections, but without relief. 
The patient underwent excision of the third webspace Morton's neuroma. Post operatively, the patient had pain, discomfort and purulent drainage. The patient was treated with a course of oral antibiotics - cephalexin. Subsequently, the patient underwent debridement of the concerned area. Further follow up showed that the patient had returned with complaints of worsening pain and burning. The patient was on cephalexin antibiotic, and she was noted to have serosanguinous drainage. 
The patient returned eight days later with complaints of swelling and burning and difficulty ambulating for more than 15 minutes. Five days after, the patient woke up with severe pain but no fever. The patient was evaluated and was noted with tenderness of the right plantar region, and drainage from the right incision and drainage (I&D) site. Magnetic resonance image (MRI) suggested the possibility of an abscess, without evidence of osteomyelitis. A superficial culture was taken, that subsequently grew group A streptococcus. The patient was evaluated and admitted to inpatient hospital stay and the patient underwent incision and drainage. The wound was irrigated with antibiotic solution and partially closed with lodoform gauze. Vancomycin 1000 milligrams intravenously every 12 hours, and Zosyn 4.5 grams intravenously every 8 hours were initiated.
The next day, the patient was evaluated by Infectious Disease who recommended continuation of current antibiotics pending operating room culture results. The patient was treated with Oxycodone for pain and given intravenous Reglan for nausea. 
On Day #2, the patient's wound was redressed - packed by the surgeon. A plan for daily repacking/redressing was made to continue for about a month post discharge. Infectious Disease recommended to change antibiotic to Penicillin intravenously every 4 hours and stop Zosyn / Vancomycin based on culture results from operative room growing Group A streptococcus. 
On Day #4, the patient was noted to be improving and stable. Intravenous antibiotics were stopped, and the patient was started on Amoxicillin and was discharged.

The proposed treatment was medically necessary.

Before admission to hospital, the patient was evaluated - treated and underwent drainage, antibiotics and clinical evaluation at least three times over the prior three weeks. The patient continued to have persistent and progressive symptoms, and this required admission to the hospital to perform incision and drainage and to ensure the patient continued to respond to the drainage, antibiotics and wound care before a discharge home could be considered. In addition, the magnetic resonance image obtained showed presence of possible abscess that needed drainage. The patient had already failed oral antibiotics and incision drainage prior to that and had continued to have persistent symptoms. After admission, the patient was treated with intravenous antibiotics and evaluated by infectious disease and based on the culture results, the antibiotic coverage was changed to Penicillin intravenous. The patient continued to show improvement and was discharged on oral antibiotic amoxicillin.
Inpatient stay was medically appropriate to perform incision and drainage and to give antibiotics, continue daily wound packing in the immediate post-operative period and to ensure that the antibiotic regimen was adjusted based on operative room culture results before the patient was discharged to ensure that patient continues to improve.