Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscesses on leg
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a previously healthy male teenager that presented to the emergency department (ED) for evaluation of a right thigh cyst-like lump that had been present for three weeks, getting worse with formation of a new lesion, painful. He had been seen in another clinic previously. 

Vital signs included temperature 101 with spike to 102.2, heart rate 128, respiratory rate 18, and blood pressure 124/85. Examination was significant for no acute distress, clear lungs, regular heart rate and rhythm, benign abdomen, multiple indurated areas to the right thigh and right knee with cellulitis, an six centimeter (cm) tender area in the anterior part of the thigh and an eight centimeter tender area on the posterior aspect of the thigh with ecchymoses and a slightly open sore, and non-focal neurologic exam.  Laboratory evaluation was significant for leukocytosis (white blood cell [WBC] count 12.4K with increased neutrophils) and elevated C-reactive protein (CRP) (3.5). Electrocardiogram was unremarkable. Chest x-ray was unremarkable. 

The patient was diagnosed with cellulitis complicated by abscess formation. Surgery was consulted, with plans to take him to the operating room (OR) for drainage following admission. The patient was treated in the ED with Tylenol, vancomycin (developed red man syndrome and was treated with Benadryl), Zosyn, and ibuprofen. Admission orders included continuation of vancomycin premedicated with Benadryl, Zosyn, anti-pyretics, and regular diet. The patient was taken to the OR the next day for incision and drainage of the abscesses. The wounds were irrigated and packed with iodoform gauze. 

The following day, the patient was doing well, tolerating a regular diet, continuing on parenteral antibiotic therapy. The wound care team recommended twice weekly wound dressing and packing. Care management options included outpatient wound care or twice weekly in-home services. He was discharged the day after to complete seven days of Bactrim and follow-up in Surgery Clinic for wound care. Cultures eventually returned positive for Staphylococcus aureus resistant to oxacillin.

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. 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.... 

This teenage male presented to the ED with significant cellulitis and three abscesses that required drainage. He was started on parenteral antibiotics in the ED and was taken the morning of admission for incision and drainage. He did well post-operatively, tolerating his diet, with no fevers and improvement in his wounds. He was evaluated by the wound care team on post-operative day two at which time it was determined that he would require twice weekly dressing changes. It is unclear why the consultation did not occur prior to that time. Based on the patient's clinical status, he was overall stable for discharge on post-operative day one. While it was reasonable to monitor him for 24 hours post-operatively, with the additional parenteral antibiotics and wound care, he did not require acute inpatient admission and could have been safely managed at observation level of care. This is consistent with recognized guidelines as well (cellulitis with cutaneous abscess, fever greater than 99.4, WBC count greater than 12K, no failed outpatient management, and interventions to include anti-infectives and incision and drainage).