Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Localized Skin Infection With Swelling and
Redness In Left Armpit (axilla)
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

Yes, the Inpatient admission was medically necessary.

The patient is a teenage male that presented to the ED for evaluation of left axillary abscess. A lesion was noticed three weeks prior, and one week prior, he was seen by Dermatology. The abscess was drained, and he was prescribed amoxicillin. He was seen in the ED and diagnosed with persistent left axillary abscess. He underwent incision and drainage (I&D), and he was prescribed clindamycin. He followed up in the surgery clinic the next day, and when the packing was removed, a large amount of purulent drainage was present, along with erythema. He was referred back to the ED. 

The patient's vital signs included temperature 37.1, heart rate 82, respiratory rate 18, and blood pressure 111/82. Pain was rated 3/10. Examination was significant for non-toxic appearance, left axillary area with abscess incisional site with bloody drainage, induration surrounding the incisional site approximately 5 cm in diameter with surrounding blanching erythema that was warm and tender to touch, and non-focal neurologic exam. Surgery was consulted, with recommendations for blood work and admission to the Surgery service. CBC (complete blood count) revealed normal WBC (white blood cell) count (10.49K) with left shift (71.8% neutrophils). Admission orders included bedside I&D, parenteral clindamycin, pain control, and regular diet. 

The patient remained afebrile, with improvement in erythema. He was deemed stable for discharge to complete the course of clindamycin and follow-up in Surgery clinic.

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.

MRSA (methicillin-resistant Staphylococcus aureus) causes both nosocomial and community-acquired infections. Guidelines have been developed for management of this potentially severe and debilitating condition. For skin abscesses, the first line of treatment is incision and drainage. Antibiotic therapy is generally recommended for severe disease, extensive disease, or rapidly progressive disease. Empiric therapy of outpatients with purulent cellulitis in the absence of drainable abscess involves five to ten days of therapy. Oral antibiotic choices include clindamycin, Bactrim, doxycycline, and Zyvox. For hospitalized patients with complicated infections, parenteral therapy with either vancomycin or Zyvox is recommended. The spectrum of infection caused by MRSA includes skin and soft tissue infections, pneumonia, bone and joint infections, central nervous system disease, toxic shock syndrome, sepsis, endocarditis, and bacteremia, which typically accompanies the majority of invasive cases. Severity ranges from simple abscess to life-threatening disease.

This young man presented to the ED after having undergone incision and drainage of a left axillary abscess followed by a course of amoxicillin, re-incision and drainage in the ED a week later, followed by a course of clindamycin, and persistent purulent drainage noted in Surgery Clinic, prompting the referral to the ED for additional management. He had initially been treated with an antibiotic not customarily used for suspected MRSA infections. However, after the second incision and drainage, he was prescribed clindamycin, frequently a first-line choice for suspected MRSA infections. He failed both outpatient interventions, this time requiring parenteral treatment and aggressive wound debridement. He responded well to this course of therapy, and he was able to discharge home fairly quickly. Regardless of the length of stay, because he had failed outpatient treatment multiple times and required parenteral therapy, acute inpatient management was medically necessary and appropriate.