Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis, Dog bite. 
Treatment Inpatient Hospital Stay. 

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

The patient presented to the emergency department (ED) with two days of worsening right hand swelling, paresthesias and redness after she was bitten on the right fifth finger by her dog. Initial evaluation was notable for leukocytosis (14.7), mild anemia (hemoglobin [Hgb] 10.8), a 1-centimeter (cm) laceration over the middle phalanx of the right fifth finger, edema throughout the right hand, and cellulitis of the right hand with lymphangitis to the right upper arm. Radiographs showed a nondisplaced fracture of the middle phalanx of the right fifth digit. She was given a Tdap [tetanus, diphtheria, and pertussis] vaccine and started on intravenous (IV) vancomycin and Zosyn before being admitted for continued management. 

The initial treatment plan included blood cultures, telemetry, nothing by mouth (NPO) status, a hand surgery consult, continuing IV vancomycin and Zosyn, IV hydration and IV morphine as needed (PRN) pain. The antibiotics were narrowed to IV Unasyn only and Infectious Disease (ID) was consulted. A volar splint was applied to the affected hand. The infectious disease (ID) consultant also added clindamycin and recommended elevating the right upper extremity (RUE). The swelling and erythema were noted to be somewhat improved. The hand surgeon recommended outpatient follow up to address her fracture once her infection was under control. The erythema had resolved, and the RUE swelling continued to improve gradually. She was felt to be safe to change to oral antibiotics, so her regimen was consolidated to oral Augmentin, and she discharged home to complete another 10 days of treatment. At issue is the medical necessity of an inpatient stay. 

The entire admission was medically necessary at the inpatient level of care. She presented with rapidly progressive right-hand cellulitis and lymphangitis following a dog bite. Even in the absence of sepsis, this clinical picture warrants admission for parenteral antibiotics (Eron et al; Raff and Kroshinsky). Based on her initial assessment, the patient was at high risk for progression to sepsis, bacteremia, septic arthritis, deep abscess formation and osteomyelitis (Franko and Abrams). The admitting physician was concerned enough for a deep hand infection that he requested immediate surgical consultation and made the patient NPO status with concern that she might require urgent intervention. Given this level of concern, inpatient admission was warranted for empiric IV antibiotics, expedited infectious workup and monitoring for complications.
The patient met Milliman Care Guidelines (MCG) for inpatient admission for cellulitis due to her urgent need for parenteral antibiotics. Given the rapid progression of her infection and associated risk of adverse outcomes, it would not have been appropriate to discharge the patient with oral antibiotics and outpatient follow up. Inpatient hospitalization was also necessary to exclude the presence of secondary bacteremia, assess for the presence of deeper infection and to ensure improvement in her hand symptoms with empiric antibiotics. Outpatient treatment would have placed her at an unacceptably high risk for sepsis, bacteremia and permanent loss of function in the affected hand.