Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Dog Bites.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

This patient is a man. He presented to the ED (emergency department) having sustained multiple dog bites to all extremities over the week prior to his presentation.  There were bilateral upper extremity lacerations and bilateral lower extremity lacerations in many stages of healing with associated cellulitis.

The patient's vital signs were significant for a normal heart rate, no fever, and normal blood pressure at presentation.  The WBC (white blood cell) count was elevated at 16 K (thousand).  Serum lactate was elevated at 10.

Following ED (emergency department) evaluation, the patient was admitted to the trauma service.  He was treated with IV (intravenous) antibiotics.  He underwent an incision and drainage procedure performed at the bedside with local anesthetic.  Day two, the patient was without new complaint and had normal vital signs.  The WBC (white blood cell) count was normal at 8.9 K (thousand).  He tolerated a regular diet and was instructed on proper wound care.  Dressing changes were performed.  He remained clinically stable and was able to be discharged from the hospital on day three with instructions for continued outpatient follow up.  During the course of care for this patient, consultations were obtained from the trauma surgery service, psychiatry, and social services.

The health plan rationale for denial per the letter is that the patient's condition and ongoing care needs did not warrant inpatient admission. They further opine that the patient's clinical needs, including the bedside incision and drainage procedure, could have been appropriately satisfied with a lower level of care.

Yes, the Inpatient admission was medically necessary.

This patient presented to the ED (emergency department) with multiple dog bit injuries and manifestations of infection/sepsis.  The WBC (white blood cell) count was elevated at 16 K (thousand). The examination identified cellulitis surrounding the multiple dog bites of the extremities, and serum lactate level was elevated at 10 K (thousand).  The patient required provision of IV (intravenous) antibiotics and a surgical incision and drainage procedure.  There was the reasonable clinical expectation that this patient had the potential for rapid clinical deterioration due to his presenting condition.  There was also the reasonable expectation that his necessary care would span a period of greater than two nights.  An observation level of care would not have satisfied the clinical needs of this patient on the dates in question.  This lower level of care would not have appropriately provided for monitoring with repetitive vital signs, lab data, surgical treatment, and overnight care for this patient with cellulitis related to multiple lacerations and need for surgical drainage.

An inpatient designation was medically necessary and consistent with generally recognized standards of medical care.  This patient demonstrated systemic infection with leukocytosis and elevated serum lactate at presentation. He required surgical treatment and provision of IV (intravenous) antibiotics and this care was reasonably anticipated to span a period of greater than two nights.  An inpatient designation was medically necessary in this case.