Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Draining dehisced wound of the left thigh. 
Treatment: Inpatient admission. 

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

The patient is a female that presented with a draining dehisced wound of the left thigh. There was reported fever to 101 degrees Fahrenheit (o F) at home. The patient's past medical history is significant for sacra agenesis, out-toeing due to bilateral femoral retroversion status post bilateral femoral osteotomies, revision of right periprosthetic fracture, and subsequent hardware removal. 

On presentation, the patient was tachycardic with a pulse of 140 beats per minute with a temperature of 100.2o F. Subsequently the patient had fever to 103.6oF in the emergency room (ER). White blood cell count was elevated (16,700) and C-reactive protein (CRP) was markedly elevated. The patient was anemic with a hemoglobin of 10.6 grams per deciliter (g/dl). Blood cultures were obtained and antibiotics were started. Orthopedic Surgery was consulted because of the wound drainage at the incision site from recent hardware removal. Initial consult note from Orthopedic. Physical examination showed two areas of wound dehiscence along the left thigh. Magnetic resonance image (MRI) was ordered to rule out bony infection. 

The patient was admitted to acute inpatient level of care. Pediatrics was consulted for management. The patient was made nothing by mouth (NPO) for possible surgery. Broad spectrum antibiotics were started. Magnetic resonance image completed on the evening of presentation did not demonstrate bony infection of deep wound infection. Case request was ordered. The next day, the patient underwent incision and drainage of the left thigh wound with application of wound VAC (vacuum). The wound was debrided to the level of the bone. 

Following surgery, the patient was afebrile. Antibiotics of Zosyn and vancomycin were continued. Wound cultures were pending. Blood cultures were reported as now growth.  The patient underwent evaluation by Physical Therapy. The patient was cleared for discharge. Antibiotics were switched to oral form. The wound VAC (vacuum) was removed prior to discharge and soft dressing applied. 

Yes, in part; the proposed inpatient admission, only the first two days were medically necessary.  However, the proposed inpatient admission for the remaining two days was not medically necessary; there was a delay in treatment of greater than (>) 24 hours which delayed discharge. 

The patient is a female that presented to with a draining dehisced wound of the left thigh. There was reported fever to 101oF at home. The patient has had orthopedic procedures on her femurs and had hardware removed two months prior. She presented with fever, tachycardia, and white blood cell count in conjunction with a draining dehisced wound from which the hardware had been removed. The patient met pediatric systemic inflammatory response syndrome (SIRS) criteria and in conjunction with a source of infection met criterion for sepsis. Pediatric criteria for SIRS (Systemic inflammatory response syndrome) are two or more of the following: fever greater than (>)101.3oF, tachycardia, tachypnea, and / or elevated white blood cell count. One of the criteria must be temperature or elevated white blood cell count. For sepsis, early and aggressive source control should be a top priority including drainage, debridement, and surgical intervention. Empiric antibiotic therapy should be administered within one hour of clinical suspicion and were administered in the Emergency Room. Blood cultures should be obtained prior to administering antibiotics is possible. 

The patient underwent a magnetic resonance image (MRI) to determine the extent of infection and to determine if there were signs of osteomyelitis. Positive cultures are not a diagnostic criterion of pediatric sepsis, and many cases of sepsis do not have positive blood cultures. Prompt and aggressive treatment of sepsis is consistent with the "treatment" of an inpatient admission. Following the magnetic resonance image which was reported that evening, the patient should have undergone incision, drainage and debridement. This did not occur until the next afternoon which was 19 hours after the magnetic resonance image (MRI) and 30 hours after the patient presented. The patient improved after drainage and no longer had fever. Had the surgery been done that afternoon or evening, the patient could have been discharged. Therefore, the delay in treatment led to an unnecessary additional day. 

No, in part; the health plan did not act reasonably or in the best interest of the patient in denying the inpatient stay for first two dates of service. However, the denial of the remaining inpatient days was reasonable. 
The patient presented the emergency room. She clearly met criteria for sepsis with fever, leukocytosis, and source of infection. Aggressive and early treatment of sepsis is crucial in improving outcomes and in preventing deterioration including multi-system organ failure. Based on the information available at the decision to admit was made, the patient was appropriate for acute inpatient level of care. The patient was expected to require at least two past-midnight days while receiving intravenous antibiotics and awaiting results of blood and urine culture. She also required emergent surgery for a surgical wound infection (source control). 

Regarding the inpatient day on day three, this was the result of a delay in treatment of the documented wound. Had the debridement and irrigation been done in a timely fashion, it would have expedited the patient's recovery with discharge a day earlier.