Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eczema.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient is a male infant with a medical history significant for possible eczema who was taken to the emergency department (ED) for evaluation of recurrent erythematous rash on the face, upper and lower extremities, and trunk. The rash initially presented at about two months of age, was treated with mupirocin and hydrocortisone with limited improvement. He was seen in the ED approximately ten days prior to this presentation at which time would culture was negative. Herpes simplex virus (HSV) was also negative. He was sent home with oral acyclovir and clindamycin for seven days. After he completed the course, he was seen in the infectious disease (ID) clinic, noting improvement in the rash with no new lesions. The medications were stopped. Since that time, the rash returned. He was otherwise healthy with no fevers, good appetite, no gastrointestinal (GI) or upper respiratory infection (URI) symptoms.

The examination was significant for no apparent distress, no oral lesions, well-appearing, clear lungs, benign abdomen, non-focal neurologic exam, and diffuse erythematous macules and patches across the face, scalp, anterior and posterior trunk, upper and lower extremities, most concentrated on the face and cheeks, mostly dry, some with yellow drainage, with no bullae or vesicles. Pediatric ID was consulted. Recommendations included methicillin-resistant staphylococcus aureus (MRSA) / methicillin-susceptible staphylococcus aureus (MSSA) nasal swab for polymerase chain reaction (PCR), HSV wound culture from an unroofed wound, and complete blood count, with admission until HSV could be ruled out. Dermatology was also consulted with recommendations not to treat with antibiotics/antivirals, use hydrocortisone, mupirocin, and petroleum jelly. Lab results included sodium low 129, potassium elevated due to hemolysis, low carbon dioxide (CO2) 15, and elevated platelets 510 thousand (K). Admission orders included mupirocin, hydrocortisone, petroleum jelly, follow-up HSV and MRSA/MSSA results, follow-up wound culture, parenteral clindamycin, parenteral acyclovir, regular diet for age, intravenous (IV) fluids, and consideration for additional labs.

Overnight the rash became more dried out and crusting over. Repeat labs showed normalization of sodium, potassium, and CO2. He continued acyclovir pending a second HSV PCR result (the first was negative). The following day, both acyclovir and clindamycin were discontinued. Per Dermatology recommendations, the baby was discharged on a topical regimen with close Dermatology follow-up and referral to Allergy/Immunology clinic.

At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary. While it was important to monitor the baby in the hospital and treat pending lab results for HSV and MRSA, the baby was overall well with no constitutional symptoms. He did not require acute admission. He could have been managed at a lower level of care.

Eczema herpeticum involves viral infection of an existing inflammatory dermatosis such as atopic dermatitis. The most common viral agents are the herpes simplex viruses, both 1 and 2. Risk factors include more severe atopic dermatitis, younger age, and location in metropolitan areas. The rash typically appears as an erythematous eruption with papules and vesicles, some with erosions and crusting. Fever is not always present. Superinfection with bacteria or fungi is not uncommon, particularly Staph. This is considered to be a medical emergency because of the potential for severe complications. Treatment includes acyclovir. Hospitalization is necessary in severe cases or when the patient is immunocompromised.

There is also increased risk of bacterial superinfection, which may progress from localized to systemic if left untreated. Staphylococcus is the most common organism to cause such infection, presenting with weeping lesions both pustular and crusting. There is some difficulty with diagnosis because of the ubiquity of the organism on the skin and the overlap in signs and symptoms between infection and inflammation. In addition to Staphylococcus (Staph) and HSV, fungal infections may also occur.

This young male infant presented with worsening and improving rash overlying a probable diagnosis of atopic dermatitis (eczema). While it was important to aggressively manage the rash to prevent further morbidity, he was overall clinically stable with no fevers or other constitutional symptoms. He did not require acute inpatient admission and could have been safely managed at a lower level of care.