Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Finger Pain and Swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a female. She has had issues associated with left finger pain and swelling. Records from  emergency room note a patient presenting with complaints of some finger swelling and pain. There was severe swelling and tenderness over the second digit for which a picture accompanied the evaluation with severe swelling dorsally, blistering type formation appreciated within the picture itself extending into the dorsal of the related hand and into the digit.

Noted was that the patient was afebrile. This patient was admitted because of the significant issues present. A discharge summary was noted the following day stating the issue was crack cocaine abuse in a patient who presented with significant swelling of the index finger. There was denial of any puncture wound intravenous drug use or injury. The hospital course noted significant subcutaneous infection likely present with tracking into the hand and forearm - possible necrotizing fasciitis. 

The patient received operating room treatment with irrigation debridement with initiation of broad-spectrum antibiotics. Infectious disease was consulted for antibiotic recommendations. Noted is that the patient left against medical advice prior to being evaluated further by Infectious disease. It was noted that the dressings were clean and dry with no abnormal erythema and the patient was moving the digits with good capillary refill. Follow-up with orthopedic clinic was recommended with discharge medications of Augmentin and doxycycline.

Yes, the proposed treatment, inpatient admission, is considered medically necessary for the treatment of the condition because of the acute nature of the swelling as noted under the emergency room department records.
The consideration for medical necessity in accordance with the New York External Review describes medical necessity for emergency room cases as:
A medical or behavioral condition that manifests itself by acute symptoms of severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (A) placing the health of the person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy, or (B) serious impairment to such person's bodily functions; (C) serious dysfunction of any bodily organ or part of such person; or (D) serious disfigurement of such person.

The picture from the emergency room clearly indicates the significant swelling about the digit that would be consistent with the clinical exam described supporting the specific indications for medical necessity in regards to the need for inpatient admission.

Per Green's Operative Hand Surgery: "Hand infections can result in severe disabilities, including stiffness, contracture, and amputation. These complications have been significantly reduced through the introduction of antibiotic therapy in conjunction with surgical treatment. Although antibiotics have dramatically reduced the morbidity associated with hand infections, their use does not supplant the need for expedient and proper surgical intervention. Several factors influence the outcome of hand infections: location of the infection, the infecting organism, timing of treatment, adequacy of surgical drainage, efficacy of antibiotics, and health status and immunocompetence of the host." 

The denial of treatment at the inpatient level of care was not in sound medical judgment and/or in the best interest the patient.  It was medically appropriate for the treatment that was provided with debridement given the concerns noted for which the references detail support of the treatment that was undertaken.  It is notable that the patient was taken to the operating room and that it was necessary for Infectious disease follow-up along with cultures to be evaluated within 48 hours.  In that way the appropriate use of antibiotics could then be undertaken.  This individual signed out against medical advice but it should be noted that the acute inpatient admission was appropriate since, as the references detail, it is necessary to define and treat the infection - with that, obtaining cultures which was undertaken, allowing the cultures to demonstrate bacterial growth which is often 48 hours, and individual need to be indicated - rather than observation status.  Therefore it would not be appropriate for observation status.  In this instance the health plan was not acting in the appropriate best aspect for the patient in that the standard of care would be an admission with evaluation of cultures within 48 hours after debridement and the operating room.

Therefore it was appropriate for this individual to receive treatment at the inpatient level of care; inpatient admission should be approved as was provided and is reasonable for the significant condition that was noted in the emergency room department, subsequent surgery and recommendation for further treatment with antibiotics.