Appeal type: Medical necessity
Decision: Overturned

This is a patient with no significant past medical history who presented to the emergency room (ER) with left ear swelling for the past two weeks. Per her mother,  the patient went swimming in a community pool and two days later she started developing redness on the outer left ear. The mother initially thought it was a mosquito bite and applied Neosporin to the affected area but did not see any improvement. The patient's left ear worsened and was swollen, tender, and painful. Pus was also noted but no blood was noted. Her mother gave Tylenol for pain and tried to schedule an appointment with the primary medical doctor (PMD) but stated she was not in the office. There was no fever or upper respiratory infection (URI) symptoms. There was no trauma to the ear or hearing loss. There were no recent travel or sick contacts. She denies nausea, vomiting or diarrhea.
The patient was admitted to Pediatrics for left ear perichondritis versus possible preauricular sinus infection for intravenous (IV) antibiotic administration. The admission exam revealed that the left pinna was very swollen and erythematous and tender to touch with a preauricular sinus and minimal drainage. There was no mastoid pain or swelling.
In the emergency room, Pediatric Ear, Nose, and Throat (ENT) and Infectious Disease consulted. Lab results showed a white blood cell count of 12.1 with elevated neutrophils. A wound culture was sent. The patient was started on IV Zosyn per the recommendations of infectious disease for potential Pseudomonas and Gram positive streptococcus/staphylococcus (strep/staph) infection. ENT was also consulted and recommended IV clindamycin. ENT felt it would be better to treat the infection and plan for possible surgical resection of preauricular sinus tract as an outpatient. Clindamycin was discontinued the morning after admission to the floor. While the patient was on the pediatric floor, pain in the left ear significantly decreased in severity since being in the emergency room. There was minimal pus drainage as well as dried blood on the outer ear that was cleaned out with gauze and normal saline the morning after admission and several times throughout the stay. No mastoid pain or swelling was noted on exam. There was no proptosis, no sinus pain. The patient remained afebrile and vital signs remained stable. The patient had difficulty sleeping because she was sleeping on her left side on the ear so she was switched to sleeping on the other side and the discomfort resolved. The external ear was tender to touch but there was no pain otherwise. Throughout the two days on the floor there was a significant decrease in swelling and erythema of the pinna. She denied hearing difficulty. She was eating and drinking well with no difficulty. IV Zosyn was discontinued in preparation for discharge and patient was transitioned to by mouth (PO) Levaquin. 
The health plan's determination is overturned. This patient presented with a left ear perichondritis that started approximately 10 days prior to presentation. She was not treated with oral antibiotics prior to her presentation therefore by the time she presented to the ER her infection had progressed and was in a location that IV antibiotic therapy and close monitoring would be recommended as it was a more severe case. The area involved, the pinna of the ear, is one that receives less circulation which can lead to treatment failure and progression of disease. Surgical intervention is not uncommon and when Pseudomonas is suspected it can be associated with a more advanced clinical presentation. As this patient was in a public swimming pool just prior to the onset of symptoms, Pseudomonal infection is of concern. IV antibiotics with pseudomonal coverage in as well as close monitoring for progression would be medically necessary.