Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dog bite to the face
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female child. She presented to the ED (emergency department) following a dog bite to the face. It was unwitnessed, considered likely provoked. Per the older sibling, the child was lying on the ground, and the dog stepped on her face. The laceration was to the right eyelid close to the eye and medial canthus, with no obvious injury to the eye.

The patient's vital signs included temperature 36.7, heart rate 134, and respiratory rate 26. Examination was significant for no acute distress, extraocular movements intact, laceration to the upper and lower right eyelid next to the epicanthal fold, regular heart rate and rhythm, clear lungs, and non-focal neurologic exam. Fluorescein testing was negative for corneal abrasion. Laboratory evaluation was unremarkable. Ophthalmology was consulted with recommendations to repair the laceration in the operating room with possible nasolacrimal stent placement.

The patient was started on maintenance IV (intravenous) fluids, nothing by mouth, with initiation of Unasyn and topical Bacitracin. She was admitted for surgery the following day. She did well post-operatively, tolerating regular diet for age, remaining hemodynamically stable with adequate pain control. Per Pediatric Infectious Disease, she did not require post-exposure rabies prophylaxis. She was discharged home to complete a course of Augmentin and follow-up with Ophthalmology in a week.

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 child presented to the ED (emergency department) with laceration versus dog bite injury to the right eyelid. Her vision and extraocular movements were intact with no corneal injury. Ophthalmology was consulted with recommendations to repair under anesthesia in the operating room. She was admitted overnight with IV (intravenous) fluids, IV (intravenous) antibiotics, and nothing by mouth in anticipation of surgery. She did well post-operatively and was discharged home following recovery to complete antibiotics course with Augmentin and follow-up with Ophthalmology. While it was reasonable and appropriate to monitor the child overnight pending surgical repair in the operating room under anesthesia, she was overall hemodynamically stable with well-managed pain, no evidence of impending sepsis, and no injury to the globe. She did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care.