Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Rash.
Treatment: Inpatient admission.

The insurer denied: Inpatient admission.  The denial is upheld,

The patient is a school-aged male child with medical history significant for eczema. He presented to the emergency department with diffuse rash. According to family, it started as a lesion on the right thigh then progressively spread over his trunk, buttocks, and genital area. The rash was painful and occasionally pruritic. He had recently returned from the Dominican Republic a week prior. The rash developed while he was there. He was otherwise doing well. The patient's vital signs included temperature 36.9, heart rate 105, respiratory rate 20, and blood pressure 99/60. Examination was significant for moist mucous membranes; regular heart rate and rhythm; clear lungs; benign abdomen; erythematous penis and scrotum; pustular papules over his trunk, as well as buttocks, thighs, legs, and upper limbs, with erythema in the gluteal cleft; and non-focal neurologic exam. There was no involvement of mucous membranes, palms, or soles. During the exam, the patient became very pale, with nausea and an episode of vomiting. He was tachycardic with standing, with decrease in heart rate upon lying down. He was given an intravenous fluid bolus for orthostatic changes, as well as empiric antibiotics after cultures were obtained. The patient's laboratory testing revealed white blood cell count 16.3K (thousand) with 81.3% (percent) neutrophils, hemoglobin 11.8, platelets 211K (thousand), C-reactive protein 18.8, glucose 110, CO2 (carbon dioxide) 24, alkaline phosphatase 179, and erythrocyte sedimentation rate (ESR) 17. He was admitted for further management. Admission orders included continuous cardiopulmonary monitoring, regular diet, follow-up cultures, ceftriaxone, and Zofran as needed. Following admission, the patient remained afebrile, tolerating his diet. The rash became dry with less erythema. Dermatology and infectious disease consultations were sought with consideration for impetigo secondary to methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant Staphylococcus aureus (MRSA) infection and recommendations to obtain wound culture. The wound culture was positive for group A Streptococcus; blood culture remained negative. He was treated with doxycycline; ceftriaxone was discontinued. Both cardiology and neurology were also consulted because of the pre-syncopal episode, with recommendations to obtain an electrocardiogram and echocardiogram. The electrocardiogram revealed T-wave inversion in V1-V4 (prevertebral segment of vertebral artery- intracranial segment of vertebral artery); the echocardiogram was normal except for mild right ventricular hypertrophy. He was scheduled for outpatient cardiology follow-up. He was deemed stable for discharge on day #4 to complete a course of doxycycline to cover possible methicillin-resistant Staphylococcus aureus, steroid cream and calamine lotion as needed for itching, and oatmeal baths.

The Inpatient admission was not medically necessary.

This male child with history of eczema presented to the emergency department with a diffuse spreading pustular rash. Palms, soles, and mucous membranes were spared. He was afebrile with no other constitutional symptoms. Both infectious disease and dermatology consulted following admission, in agreement that the child had an infectious rash, methicillin-resistant Staphylococcus aureus (MRSA) may be involved, with recommendations to treat with a course of doxycycline. Cultures subsequently grew group A Streptococcus. He had a pre-syncopal episode in the emergency department prompting neurology and cardiology consultations. There were some minor changes on electrocardiogram and echocardiogram, with recommendations to follow-up in the outpatient cardiology clinic. While it was reasonable to monitor him in the hospital for progression or resolution of the rash, involving multiple consultants, he was overall hemodynamically stable with no evidence of life-threatening rashes like Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN), or SSSI (skin and skin structure infection) and no intractable pain. He did not require acute inpatient admission and could have been safely managed at lower level of care.