Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain and rash 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is overturned. 

The patient is a male child that was referred to the emergency department (ED) from Urgent Care with three-day history of worsening rash on his abdomen, associated with abdominal pain but no fever at home. Vital signs in Urgent Care included temperature 100.9. He was treated with Tylenol prior to transfer. 

Vital signs in the ED included temperature 102.0, heart rate 152, and respiratory rate 26. Examination was significant for crying with exam, moist oral mucosa, abdominal tenderness with guarding, eight by three centimeter (cm) erythematous rash with induration over the right lower abdomen with a whitehead noted at the top of the rash, no palpable fluctuance, and non-focal neurologic exam. Laboratory evaluation was significant for leukocytosis with white blood cell (WBC) 20.5K and left shift (74.3% neutrophils), elevated C-reactive protein (CRP) (2.147), elevated erythrocyte sedimentation rate (ESR) (27), and blood culture pending. Bedside ultrasound revealed cobblestoning without fluid collection. The patient was treated with ibuprofen, Ancef, and Bactrim prior to admission for further management of cellulitis. 

Admission orders included continued Ancef, antipyretics, and close monitoring of progression of the cellulitis. Pediatric Surgery was consulted, with concern for abscess and recommendation for incision and drainage. The child underwent incision and drainage under propofol sedation, with expression of approximately five milliliter (mL) of purulent fluid. A vessel loop was left in place to facilitate drainage. The erythema was noted to have spread, including the region above his groin and his scrotum. His appetite was improving and his fever curve was trending down. He remained on parenteral antibiotics (changed to vancomycin) and warm compresses. 

The patient was afebrile, with negative blood cultures and swab culture positive for Staph aureus. His antibiotics were changed to Bactrim by mouth. He was deemed stable for discharge later that day. The swab culture returned positive for methicillin resistant staphylococcus aureus (MRSA) sensitive to Bactrim. 

Yes, the inpatient admission was medically necessary. 

This young child developed a small rash on his abdomen that progressed rapidly over the course of three days, with resultant cellulitis as well as constitutional symptoms (fever, elevated inflammatory markers, poor appetite). He was treated with parenteral antibiotics and admitted for further care. Abscess was noted following admission, so he underwent incision and drainage of the area productive of purulent material. He continued to have fevers with slowly improving fever curve. The erythema initially spread from his abdomen down to his scrotum then began to improve. His appetite slowly improved over the course of his hospital stay. It took several days for these improvements, indicators that the antibiotic treatment was effective, to occur. In summary, this young male child presented with an aggressively spreading MRSA cellulitis complicated by abscess formation. He was appropriately admitted acute inpatient status. He could not have been safely managed at a lower level of care.