Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Foot Swelling
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.  The denial has been overturned. 

The proposed treatment was medically necessary.

The patient is a pediatric boy who had experienced multiple mosquito bites after a trip to the park.  He itched the areas a lot and had seen his pediatrician two times.  At the last visit, he was started on clindamycin.  Despite several doses (times three) of clindamycin the swelling continued and erythema worsened. He was unable to bear weight on his right foot.  He had diffuse erythema with irregular borders over the right ankle and foot--generalized non pitting edema of the entire right foot extending to shin, some erythematous streaks noted on posterior right leg.  The skin overlying the dorsum of the foot was very tense.  It was tender to palpation and with manipulation.  There was one bullae with discharge. Non-pitting edema up to the lower shin was present.  Surgery was consulted and incision and drainage was performed with no results.   Symptoms were felt to be due to cellulitis.  The patient was admitted for intravenous antibiotics.   In the emergency department (ED), the patient was afebrile but tachycardic.  Respiratory viral panel was positive; C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were normal.  The patient's white blood cell (WBC) count was 18.1.  The patient's blood culture was negative and swab of the culture was positive for enterococcus from the skin.  The patient was started on intravenous vancomycin, and was nothing by mouth (NPO) with intravenous fluids (IVFs) for possible magnetic resonance image (MRI) to rule out osteomyelitis.

The next day, there were no acute events overnight.  The patient was doing better.  Pain and itching improved.  Swelling of the lower right extremity remained but the patient was able to bear weight and walk.  He was transitioned to oral (PO) Bactrim on discharge.  Intravenous fluids were stopped.  The Plan was to discharge on tomorrow if labs and clinical exam continued to improve.  The patient's foot x-ray was without signs of osteomyelitis.

On the next day, the patient was discharged home on oral antibiotics.

The patient is a pediatric child with cellulitis of the extremity that was not improving with oral antibiotics as outpatient and had worsening symptoms: not being able to bear weight, appearance of spreading up the extremity and possible systemic involvement.  The patient had clinically worsened after approximately one day of oral antibiotics.  This patient failed outpatient management of the cellulitis with worsening symptoms and physical exam.  Cellulitis can be managed at outpatient level many times but in some instances the patient requires systemic treatment or intravenous therapy as in this case.  The peer reviewed literature supports this approach. 
      
The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  The patient failed outpatient management with oral antibiotics and therefore systemic or intravenous antibiotics were medically necessary to achieve clinical improvement.  Once clinical improvement was established the patient was changed to oral antibiotics.  The literature supports the use of systemic or intravenous treatment in patients who fail outpatient therapy for cellulitis.  These cases can rapidly spread and potentially cause systemic infection or osteomyelitis.