Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease-Bacterial infection
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient is a male child with medical history significant for eczema and penicillin allergy that presented to the emergency department (ED) for evaluation of a rapidly spreading rash on his left upper thigh. He had sustained a scrape on his left knee from a metal piece of an old window screen. The wound was cleaned and disinfected with alcohol and hydrogen peroxide. A week later he began to limp due to pain, and his mother noted a painful blistering rash that was spreading up his left leg. He was taken to urgent care and referred to the ED. Surgery was consulted for recommendations. Interventions included maintenance intravenous (IV) fluids, labs, and pain management. Laboratory testing was significant for white blood cell count (WBC) 10.1 with 75% neutrophils, C-reactive protein (CRP) 3.52, erythrocyte sedimentation rate (ESR) 10. Cultures were pending. Surgery performed a bedside incision and drainage (I&D). He was given a dose of vancomycin and admitted for ongoing management of cellulitis with abscess status post I&D. Admission orders included vancomycin, follow-up cultures, magnetic resonance imaging (MRI) study to rule out deeper abscess versus (vs) osteomyelitis, infectious disease (ID) consult, and Tylenol and Toradol as needed. Cefazolin was added because the rash, now diagnosed as lymphangitis, continued to spread despite the I&D and initiation of vancomycin. Culture returned positive for Strep pyogenes. 

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.
Lymphangitis is an infection of the lymphatic channels. It is usually caused by an acute bacterial infection, but may also be caused by parasites, mycobacteria, and malignancy. It is generally rapidly progressive and may be associated with systemic symptoms such as fever and malaise. It characteristically presents as streaking with proximal lymphadenopathy. Treatment includes antimicrobial agents with possible surgical intervention.
This male child sustained a superficial injury to his left knee and a week later had a rapidly progressing ascending painful rash extending up to his groin. He was experiencing a lot of pain, limping when able to walk. He underwent abscess incision and drainage at the bedside with Surgery and treated with vancomycin. Despite these interventions, the painful rash continued to progress. He was diagnosed with lymphangitis, Infectious Diseases was consulted, and a second antibiotic was added. He continued to receive double antibiotic therapy which stopped the progression. His pain subsequently improved sufficiently to be discharged home. This level of care is most consistent with inpatient management, including subspecialty consultations, addition of a second antibiotic when the first was not successful in stopping the progression, and surgical drainage of an abscess.