Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lyme Disease
Treatment:  Inpatient hospital stay

Six days before the day of admission the patient went to Monterey Bay.  On the day of admission, the patient noticed a skin rash on the right inner thigh.  Patient had a 5-day history of fever, itching, and a skin rash.  The patient thought that she possibly could have been bitten by a spider.  Subsequently, the patient developed a whole-body skin rash and high fever, as well as facial swelling and shaking chills.  The patient went to an urgent care clinic where a diagnosis with possible scabies and was prescribed Cetirizine.  The patient took Tylenol, and Ibuprofen for fever and Benadryl for itching.  In addition, the patient had an injection of corticosteroids in urgent care.  Following the injection of corticosteroids, the facial swelling improved.  Admission assessment was positive for fever and chills, whole body aches, and tachycardia.  The rest of the review of systems was unremarkable.  The patient had whole-body urticaria mostly pronounced on the extremities.  In addition, the patient had a target lesion on the inner aspect of the right thigh.  The diagnosis of scabies was doubted.  At the time of admission, the patient started on Prednisone and empiric treatment with Doxycycline.  Additional history was obtained, and the patient had noticed a tick in the bed, but it was not attached to the body.  It was mentioned that the patient had one target lesion on the inner thigh area.  Therefore the diagnosis of Lyme disease was seriously considered, and the patient continued to be treated with Doxycycline and apparently made improvement while in the hospital. The patient was recommended to take Doxycycline for 21 days and to follow up with her primary care physician.  The health plan's determination of medical necessity is upheld in whole.
This patient had a legitimate problem, which was most likely a presentation of Lyme disease.  Based on the patient's history including possible exposure to a tick, geographic location with a relatively high prevalence of Lyme disease, and the presence of a target lesion on the surface of the skin, the patient was appropriately diagnosed with possible Lyme disease and was started on an oral antibiotic.  Antibiotics for the treatment of Lyme disease include Amoxicillin, and Doxycycline.  Nonsteroidal anti-inflammatory drugs can be used for symptomatic relief.  In the cases when patients develop complete heart block, treatment with intravenous Ceftriaxone, as well as a temporary pacemaker might be considered.  There was no evidence that in this clinical case the patient developed complete heart block and required treatment with intravenous antibiotics or pacemaker placement.  Taking into consideration these facts, and the definitive diagnosis was unclear at the time of admission, the admission at a lower level of care was the most appropriate to come up with the correct diagnosis, monitor for clinical stability, and initiate the appropriate treatment with oral antibiotics.
Neither the severity of the patient's condition nor the complexity of the services provided justified admission at an acute inpatient level of care.