Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Dog bites
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is an male child with unremarkable medical history. He presented to the ED (emergency department) shortly after having been bitten on both upper extremities by a family dog. His immunizations were up to date. He had no constitutional symptoms. He reported pain 10/10.

The patient's vital signs included temperature 37.1, heart rate 97, respiratory rate 21, and blood pressure 117/72. His examination was significant for crying in pain, multiple dog bite puncture wounds noted on the right forearm and hand and the left hand, moderate swelling over both hands and the right forearm with severe tenderness, limited range of motion due to pain, pulses and sensation intact, and brisk capillary refill.

The patient was treated with Motrin for the pain, with good response. X-rays were obtained and were unremarkable. The wounds were irrigated with saline and dressed. He was given a dose of Unasyn prior to admission for further management and monitoring for signs/symptoms of compartment syndrome.
Admission orders included continuation of Unasyn, Motrin as needed, neuro checks every four hours, and regular diet for age. Covid testing was completed and was negative. Overnight, the patient continued to have significant pain with decreased movement of the right hand due to pain. Circulation and sensation remained intact. His pain improved over the course of the hospital stay, and eventually was able to move his fingers and wrists without limitation. He was deemed stable for discharge to complete a course of Augmentin and follow-up with his primary care physician.

No, the Inpatient admission was not medically necessary.

Dog bites account for the majority of animal bites that are evaluated in the ED (emergency department), and children are the most likely victims. Wound care involves copious irrigation to clean the wound, exploration for tendon and/or bone involvement and the presence of foreign bodies, primary or secondary closure, and antibiotic prophylaxis. The latter two strategies are based on specific guidelines. Wounds may be closed primarily, for example, if they are large wounds or those on the face. Wounds that are at higher risk of infection, such as those on the hands, should be allowed to heal secondarily. Antibiotic prophylaxis is not always necessary but should be considered for wounds that require closure and those at are high risk such as wounds to the hand and deep puncture wounds. Augmentin is considered to be the first-line treatment in the outpatient setting, typically for a three- to seven-day course of therapy.

This young male child presented to the ED (emergency department) after having sustained multiple bites to his bilateral hands and right forearm. He was experiencing severe pain, and there was concern for compartment syndrome on the right. He was treated with parenteral antibiotics until the swelling and pain had decreased sufficiently such that he was able to move his hands and wrists, at which point he was discharged home. While it was reasonable and appropriate to monitor him in the hospital for progression to compartment syndrome versus resolution of swelling, along with improvement in pain, he was overall hemodynamically stable, with no signs of impending sepsis and no neurovascular compromise of his upper extremities. He did not require acute inpatient admission. He could have been safely managed at a lower level of care, such as observation.