Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skin Lesions.
Treatment:  Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a female child with a medical history significant for eczema and Brugada syndrome, who presented to the emergency department (ED) for evaluation of worsening skin lesions. A week prior, she was in the park and sustained numerous mosquito bites (approximately twenty) with significant pruritus and scratching causing skin breakdown. She subsequently developed erythema and swelling on her arms and legs around the bites. She developed blisters with drainage on the left hand that were painful as well as a scabbed over rash on the right outer thigh. The left hand developed moderate swelling with increasing discomfort and the inability to bend her fingers fully. 
The examination was significant for no acute distress, moist mucous membranes, clear lungs, regular heart rate and rhythm, benign abdomen, left hand with diffuse swelling worst to fingers three and four with a one centimeter (cm) pustular lesion or blister to each hand, decreased range of motion with attempted bending of her fingers, erythema tracking proximally up the hand, scattered lesions over the extremities worst to the left hand and right thigh and a large six cm crusted lesion with surrounding erythema to the right thigh, non-focal neurologic exam.

She was treated with a dose of linezolid and admitted for further management with continued intravenous (IV) antibiotics. 

The infectious disease consultation yielded recommendations to continue linezolid, culture of wounds if possible. An orthopedic surgery consultation yielded recommendations to obtain STAT (immediately) dermatology consultation, no heavy lifting with the left upper extremity, elevation of the left hand, and continued antibiotics. The dermatology consultation yielded a diagnosis of bullous arthropod reaction possibly related to eczema less likely bullous impetigo and recommendations to swab for herpes simplex virus (HSV), follow-up wound culture, topical mupirocin twice daily, hydroxyzine for itching, steroid treatment for the trunk and neck, and consideration for discharge on oral antibiotics.

She remained on linezolid with improvement of the lesions. She was deemed stable for discharge to complete a course of oral linezolid and follow-up with dermatology and primary care. At issue is the medical necessity of an inpatient stay.

This young child with medical history of eczema and Brugada syndrome (asymptomatic) presented after receiving numerous mosquito bites with increasing erythema, swelling, and development of bullous lesions. She also developed some fever. She was treated aggressively with parenteral antibiotics for suspected cellulitis. Infectious disease, orthopedic hand surgery, and dermatology consultations were obtained, with dermatology diagnosing bullous arthropod reaction with eczematous reaction. She improved over the course of her hospital stay and was discharged on oral antibiotics. When she was first admitted, there was concern for progressive cellulitis or bullous impetigo. This would have been a serious complication of eczema requiring aggressive treatment. With dermatology input of exuberant arthropod reaction rather than progressive infection, she was deemed stable for discharge. Management of the originally diagnosed condition was most consistent with an acute inpatient level of care. Subsequent diagnosis did not alter the care that she received. A lower level of care would not have been appropriate in this case.