Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right-Hand Abscess. 
Treatment: Inpatient level of care admission. 
The insurer denied coverage for the inpatient level of care admission. 
The denial is overturned. 

The patient is an adult male. Per the appeal letter, he was sent to the ED (emergency department) by his orthopedic hand surgeon for new right-hand abscess in setting of multiple hand infections status post amputation of right third finger due to gas gangrene with revision 7 months ago. He had fistula on the right upper extremity, which developed vascular steal syndrome and wet gangrene of the right middle finger. He required multiple irrigations and debridement of his right hand/forearm, with eventual closure of his third digit wound. He had cultures with Escherichia coli pan-sensitive with few Strep angionosis and Bacteriodes fragilis, and he completed a six-week course of IV (intravenous) Unasyn. The patient's exam was notable for abscess of palmar surface of right hand with worsening erythema surrounding volar-ulnar aspect of right hand. He was seen by Nephrology, as he had missed hemodialysis due to going to the ED (emergency department). The patient was admitted to the surgical unit with diagnosis right hand abscess. The patient was started on IV (intravenous) Unasyn 3 grams every 24 hours. The patient was taken to the operating room and underwent irrigation and debridement of bone of hand under general anesthesia. Wet to dry dressing was applied. His neurovascular and hemodynamic status was closely monitored. Wet-to-dry dressing changes were done by the Orthopedic team. The patient was followed closely by Infectious disease specialist. IV (intravenous) Unasyn was continued every 24 hours. Nephrology followed throughout, and hemodialysis was continued. 
The vascular surgery team was consulted due to concern for steal syndrome. No acute vascular intervention was required. 
MRI (magnetic resonance imaging) performed showed abscess in the volar radial forearm. The patient was taken back to the operating room on day #11 and underwent right forearm irrigation and debridement with placement of Integra skin substitute and wound vacuum. Infectious Diseases recommended continuing IV (intravenous) Unasyn. Repeat MRI (magnetic resonance imaging) showed no osteomyelitis. He was seen by physical therapy and was assisted to weight bear as tolerated with cane/walker and bilateral prosthetics as needed. Wound vac was discontinued on day #15. Dry dressing and collagenase treatment was placed. Dressings were performed by orthopedics. The plan was for surgery for Integra versus skin graft placement. 
On day #33 the patient underwent right upper extremity irrigation and debridement of wound, partial wound closure, and placement of Integra dermal substitute. The patient also underwent repeat debridement of right index finger with placement of dermal substitute under general anesthetic. His neurovascular status was closely monitored, and IV (intravenous) Unasyn was continued per ID (infectious disease). Daily wound care was to be continued per the plastics team. Once all risks were addressed and the patient achieved hemodynamic stability, he was cleared for discharge with visiting nurse in place and instruction to continue his hemodialysis treatment as scheduled and follow-up with orthopedic and plastic surgeon within two weeks. 

The inpatient admission was medically necessary. 

The patient has a history of vascular insufficiency due to diabetes and an upper extremity fistula. He presented to the ED (emergency department) with a new right-hand infection. He had a history of gas gangrene and finger amputation in the past. The patient's infection was potentially limb threatening. The patient's history of vascular steal due to his fistula placed him at extremely high risk for amputation of his hand or forearm without aggressive and attentive intervention to prevent progression of his infection. Although the patient did not ultimately end up requiring an amputation, this could not have been anticipated at the time of presentation or during the hospital stay. Only through multiple debridement and attention for surgical and infectious disease specialists was the patient's infection able to be controlled without requiring amputation. This was an acute presentation due to the vascular steal syndrome, and the patient would have been at an extremely high risk of amputation or even death if he were to have been managed as an outpatient rather than as an inpatient. His acuity was much higher than suggested by the denial letter from the health plan. The admission was medically necessary due to the patient's high acuity and risk of limb loss.