Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right thumb pain and swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female child that presented to the emergency department (ED) with several-day history of right thumb swelling that was getting worse. She had been seen at an urgent care center where she was prescribed Keflex and Epsom salt soaks. The child indicated that her thumb was painful. There were no reported fevers or other constitutional symptoms. 

Vital signs included temperature 37.4, heart rate 105, and respiratory rate 25. Examination was significant for no acute distress, non-toxic appearance, moist mucous membranes, regular heart rate and rhythm, non-focal neurologic exam, and right hand flexor swelling with induration and erythema. The patient was diagnosed with right thumb flexor abscess. Plastic Surgery was consulted, and performed an incision with drainage of 1.5 mL purulent fluid under conscious sedation. The wound was irrigated and packed, cultures were sent, and she was given a dose of intravenous (IV) Ancef. She was admitted for continued antibiotics, wound care, and dressing changes. 

Following admission, the patient was transitioned to enteral clindamycin to cover for possible methicillin resistant staphylococcus aureus (MRSA). She did well over the course of her hospital stay with noticeable clinical improvement and no fevers. Upon cultures returning positive for MRSA, she was deemed stable for discharge home to complete a ten-day course of clindamycin.

No, acute inpatient hospitalization was not medically necessary.

MRSA causes both nosocomial and community-acquired infections. Guidelines have been developed for management of this potentially severe and debilitating condition. For skin abscesses, the first line of treatment is incision and drainage. Antibiotic therapy is generally recommended for severe disease, extensive disease, or rapidly progressive disease. Empiric therapy of outpatients with purulent cellulitis in the absence of drainable abscess involves five to ten days of therapy. Oral antibiotic choices include clindamycin, Bactrim, doxycycline, and Zyvox. For hospitalized patients with complicated infections, parenteral therapy with either vancomycin or Zyvox is recommended. The spectrum of infection caused by MRSA includes skin and soft tissue infections, pneumonia, bone and joint infections, central nervous system disease, toxic shock syndrome, sepsis, endocarditis, and bacteremia, which typically accompanies the majority of invasive cases. Severity ranges from simple abscess to life-threatening disease.

This young female child developed infection with abscess formation of her right thumb. She had no fevers or other constitutional symptoms, but because of acute worsening despite treatment with Keflex, she was taken to the ED. While in the ED, she underwent incision and drainage under conscious sedation. She was subsequently admitted for parenteral antibiotic therapy. Shortly after admission, she was transitioned to enteral clindamycin to cover for possible MRSA infection. While it was reasonable to monitor her in the hospital following wound drainage, she was overall hemodynamically stable with no evidence of worsening infection or impending sepsis. She did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care such as observation.