Appeal type: Medical necessity
Decision: Overturned

Dx: Skin Disorders
Tx: Inpatient Hospital
Denied: Inpatient stay
Denial: OVERTURNED in whole

The patient is a male with past medical history of intravenous drug use, hepatitis C, heroin dependence, cocaine use, and schizophrenia, who presented to the emergency department with left hand abscess worsening for the last week accompanied by subjective fevers and chills that developed after injecting into his hand.
On presentation, the patient was initially afebrile but then febrile to 100.9 with blood pressure 128/70, heart rate 110, respiratory rate 19, and with oxygen saturation of 100% on room air. Exam otherwise noted a large abscess on the left hand that was 5 centimeters in diameter with overlying erythema and warmth with a pustular head and no streaking with sensation intact but with motion of his hand limited in the setting of abscess. Labs resulted with white blood cell count 14.5, hemoglobin 13.4, sodium 133, glucose 133, total bilirubin 1.2, aspartate aminotransferase (AST) 56, and with the rest of his comprehensive metabolic panel within normal limits. Hand x-ray showed soft tissue swelling of the metacarpals. The patient was brought into the hospital with assessment that he had hand abscess and with plans for intravenous (IV) antibiotics and orthopedic surgery consultation.
Orthopedic surgery saw the patient with assessment that he needed emergent surgery to treat his abscess with associated limited hand motion. The patient was subsequently taken to the operating room with incision and drainage performed and Penrose drain left in place.
The patient was hemodynamically stable without fever, hypotension, or tachycardia. His pain was well controlled. Cultures grew streptococcus. Penrose drain was removed, and the patient's hand was placed in a soft wrap. Plan otherwise was for every 2 hours soaks, continuing IV antibiotics, following up culture data, and consulting infectious disease for antibiotic recommendations. Infectious disease saw the patient with recommendation that the patient could be transitioned to Keflex for a total of 1 week of antibiotic therapy.
The patient was subsequently discharged to complete a course of Keflex.
The issue in question is the medical necessity for the inpatient stay.

The health plan's determination is overturned in whole.

This is a patient who presented with hand abscess in the setting of IV drug use with accompanying leukocytosis, fever, and tachycardia and with difficulty moving his hand in the setting of pain and swelling. Impression from orthopedics was that he needed not only IV antibiotics but also emergent incision and drainage in the operating room with additional need for Penrose drain placement. The patient was high risk for complications including progression of sepsis and neurovascular compromise given his presentation with decreased hand movement as well as history of intravenous drug use (IVDU) which significantly increased his likelihood of having a high risk methicillin-resistant staphylococcus aureus (MRSA) infection. Inpatient care was medically necessary for this patient with a history of IVDU presenting with sepsis, significant hand swelling and cellulitis limiting his hand movement requiring emergent incision and drainage in addition to IV antibiotics at risk for progression of sepsis, neurovascular compromise, and at high risk of MRSA.

Inpatient stay was medically necessary. As previously noted, this patient presenting with signs of sepsis including tachycardia, fever, and leukocytosis with clear evidence of cellulitis and hand abscess limiting hand motion was at risk of progression of sepsis, neurovascular compromise, and highly virulent infection with MRSA. He required not only emergent initiation of IV antibiotics but incision and drainage with drain placement with ongoing IV antibiotics and close monitoring needed; the sum of which treatment could not have been safely provided at a lower level of care. The inpatient stay was medically necessary.