Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Toe infection. 
Treatment: Inpatient admission. 

The insurer denied: Inpatient admission. 
The denial is overturned. 

The patient is an adult female with medical history of carcinoma of fallopian tube status post-surgery/chemotherapy - the patient is now on Rubraca. The patient underwent left second toe hammer toe correction. The patient was subsequently evaluated in the Ortho Clinic and her operative toe was noted to be erythematous and swollen. The scab was removed, and the pin was pulled. The patient was started on Keflex 500 milligrams three times a day (TID) for seven days. The patient did not have improvement even after completing the course of antibiotics. A magnetic resonance imaging of the left foot was obtained and demonstrated subacute postoperative changes status post minimally invasive hallux valgus correction and pin fixation of second digit hammertoe deformity with subsequent pin removal. There was diffuse intraosseous and regional soft tissue hyperintensity with enhancement post contrast administration; while findings may reflect a regional soft tissue infection (cellulitis), findings are largely attributed to the relatively recent nature of the surgery. In view of the above magnetic resonance image (MRI) finding and non-improvement with antibiotic course of Keflex, Infectious Disease (ID) was consulted, and the recommendation was to admit patient for treatment with intravenous antibiotics. The patient was admitted with a diagnosis of second hammer toe post-operative infection / cellulitis. The patient was empirically started on intravenous Vancomycin 1000 milligrams every 12 hours and Zosyn 4.5 grams (G) every eight hours by Infectious Diseases (ID) for suspected cellulitis. Paxlovid for five days was added for immunocompromised history after testing positive to COVID. The patient was also placed on appropriate isolation precautions. She had asymptomatic COVID infection but since she was on cancer treatment, she met criteria for being high risk for progression of COVID infection. Vital signs were closely monitored with special attention to her respiratory status and oxygen (O2) saturation. The patient was followed by Infectious Disease consult and was noted to have continued swelling and redness of the left second toe. The patient underwent chest x-ray to rule out pneumonia. The patient was continued on intravenous antibiotics. On day #2, the patient was continued on intravenous antibiotics and vancomycin trough was therapeutic at 16.2. The patient was still noted with diffuse swelling but erythema had improved. In view of improvement discharge was planned for next day if the patient continued to improve and patient was discharged next day. 

The inpatient admission was medically appropriate and necessary. 

The patient had definitive cellulitis involving the left foot surgical site region and had no improvement with course of Keflex taken as an outpatient. In addition, magnetic resonance image of the left foot showed changes consistent with cellulitis and post-operative changes that were concerning. In addition, there was concern that the patient may need treatment other than intravenous antibiotics - for example, incision and drainage if there was inadequate improvement with antibiotics. The decision to admit the patient for intravenous antibiotics and for monitoring the response to intravenous antibiotics was needed to ensure that the patient was responding to the treatment being given. In addition, this was especially important as the patient was considered immunosuppressed in view of cancer and being on treatment with Rubraca for the cancer. Inpatient admission was medically necessary and appropriate for this patient in view of above clinical situation and to ensure that patient continued to improve with intravenous antibiotics and to be able to provide additional treatment as needed to ensure continued improvement.