Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rash

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient is a product of a full-term pregnancy with no complications noted in the chart. He was admitted for reported rapidly progressive rash. Evaluated by Dermatology in the emergency department (ED), he was admitted for control and evaluation of his progressive rash. Critical to the decision making for his admission were several factors. These include his very young age, rash originating in his groin 2 weeks after a circumcision, and the rapid progression of his rash. Each of these will be discussed in order as they each contributed to the concern needing admission.

Age at evaluation. As per current guidelines, admission for fever in an infant is recommended for those infants in the first 6 weeks of life. What is not fully discussed is when to admit for those who look sick and are at high risk for developing disseminated infections. When they have fever, it's easy to say admit, but when they show evidence of progressive infection its harder to say exactly when you should admit. In this age group it's easy to recognize fever, but hard to predict exactly when that fever would occur.

Herpes Simplex Virus (HSV). As noted by many, HSV encephalitis is reported in the Jewish orthodox community 1-2 weeks after a circumcision. Without knowing any details of this infant's circumcision, (and respecting that the treating medical doctors (MDs) felt the need to send for HSV polymerase chain reaction (PCR) testing) it is important to admit and test these infants for HSV. However, as per the notes, the concern for this pathogen was not high and preemptive treatment with (intravenous) IV acyclovir was not started. It was on the differential diagnosis, but not high on the list. Of importance is the assurance that the treating MD was able to send the test out on admission and get the result back within 24 hours, helping the MD correctly treat this very young infant. 

Rapid rash progression: With the (reported rapid) progressive nature of his rash, it is very reasonable to be concerned for sepsis. By preemptively admitting a neonate with signs and symptoms concerning for sepsis and early initiation for antibiotics one has the ability to prevent significant sequela. By performing a nasal swab to look for methicillin resistant staph aureus (MRSA), the treating team was very smart, as IV to oral antibiotic switches depend on concern for MRSA vs methicillin sensitive staph aureus (MSSA). I am not aware of this institution's antibiogram. As each institution reports their own past year's data on antibiotic resistance, using clindamycin may or may not be the drug of choice for presumptive MRSA. In fact, the MRSA screen culture from the nose was negative, allowing for switch to Keflex with no concern for a need to treat MRSA. Keflex/Ancef might have been an issue to use up front without knowledge of the nasal swab. 

Clindamycin: IV vs oral. It is true that oral clindamycin is very bioavailable. What is missing from this equation is the possibility that this young infant will move into sepsis and at that point oral therapy is considered suboptimal. Thus, starting with IV and observing for 12+ hours to make sure that sepsis did not occur and that oral feeds were being tolerated, the ability to switch to either oral clindamycin or Keflex is documented. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.