Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Foot Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female child that presented to the ED (emergency department) with worsening left foot pain and swelling. Two days prior she accidentally pricked her left foot with a toothpick in the space between two toes. The mother removed the toothpick and cleaned the wound, but the following day, she was experiencing pain and swelling. It continued to worsen, with such pain and swelling that she was unable to bear weight on the affected foot. She had no constitutional symptoms.

The patient's vital signs included temperature 37.4, heart rate 104, respiratory rate 20, and blood pressure 109/72. Examination was significant for left foot well-demarcated erythema and swelling of toes and metatarsal area measuring about 5x6 centimeters, able to move her toes, intact sensation, neurovascular intact. Lab testing revealed WBC (white blood count) 6.7K (thousand) with 68% (percent) neutrophils, mildly elevated alkaline phosphatase 217, mildly elevated AST (aspartate aminotransferase) 44, CRP (C-reactive protein) 2.3, and pending blood cultures. X-ray revealed soft tissue swelling of the forefoot. She was treated with Unasyn and ibuprofen prior to admission for left lower extremity cellulitis. Admission orders included regular diet, continued Unasyn, and ibuprofen for pain.

The patient was treated with nine doses of Unasyn. She was able to ambulate, had no fevers, was tolerating a regular diet. She was deemed stable for discharge to complete a ten-day course of antibiotics with clindamycin.

The inpatient hospital admission was not medically necessary.

Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as 
well as age and immune status of the patient.

This child presented with cellulitis following toothpick stick between two toes of her left foot. The pain and swelling increased so that she was unable to bear weight. Following labs and x-ray, she was treated with a dose of antibiotics before being admitted for ongoing parenteral treat with an initial dose of parenteral antibiotic in the hospital, she was overall hemodynamically stable with no indication of abscess formation, no constitutional symptoms, and had not failed outpatient therapy. She could have been safely managed at a lower level of care.