Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female who was taken to the emergency department (ED) following scald burn to the right hand. Hot tea spilled on her right hand from a tea kettle. She was treated with Tylenol and running under cool water at home with some symptomatic relief.
Vital signs included temperature 98.6, heart rate 132, respiratory rate 28, and blood pressure 104/69. Examination was significant for no acute distress, mild tachycardia, moist mucous membranes, blistering on the first three digits crossing the metacarpal joint line with surrounding erythema, and blistering of the palm and radial aspect of the fourth digit. She was diagnosed with second-degree partial thickness burn of 0.5% body surface area involving the right hand. She was treated with ibuprofen and fentanyl. Laboratory evaluation was significant for leukocytosis (white blood cell [WBC] count 22.06 thousand [K]). The burn service was consulted with recommendation for admission for observation. Admission orders included physical therapy (PT)/occupational therapy (OT) evaluation, non-excisional debridement and cleansing with chlorhexidine, daily wound care with collagenase and gentamicin, attending wound check after 24 hours of collagenase and gentamicin, pain control as needed, and diet as tolerated.
The following day, her pain was well-controlled, she was eating and drinking, and she was afebrile. However, during the wound check, the burns appeared to be significantly deeper than initially thought. At that point, her status was converted from observation level of care to acute inpatient level of care for continuing local wound care and ongoing re-evaluation of her wound status. There was some consideration for discharge, but upon wound evaluation during dressing change, the burns on the dorsum of the fingers were still quite deep. The palmar aspect of the hand was healing quite well. Local wound care was continued with collagenase and gentamicin using ibuprofen and morphine for pain management, and consideration was given for possible surgical intervention. During wound evaluation, there was still a small section on the dorsum of the index finger extending down into the first web space that was fairly deep, but the remainder of the wounds were healing well. Local wound care was recommended, and family teaching was initiated. She underwent dressing change, at which time the wounds were placed into Mepilex. She was discharged home for follow-up in Burn Clinic.

Acute inpatient stay was medically necessary and appropriate for this infant. She had initially been admitted observation status but because of the severity of the burn was appropriately converted to acute inpatient status. In this child's case, she was an infant at the time of her scald burn. She sustained second degree burns of her right-hand including fingers and joints. She was initially managed in the ED, but following initial wound care, was placed in observation status for the first wound care/dressing change. Upon evaluation, the burn was considerably deeper in some areas than previously thought. She was converted at that time to full inpatient status, and local wound care was continued. As the burn injury continued to progress, there was even consideration for surgical intervention. Based on the current standard of care and the evolving damage that became evident over time during wound care, acute inpatient status was medically necessary and appropriate. Her medical needs exceeded what could be proved as observation status.