Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient emergency admission. 
The denial is overturned.

The patient is a female who presented with new-onset blisters on her feet and hands.
She was well until the day of admission when her mother received a call from her daycare stating that she had blisters on her feet. She was initially told that the blisters were caused by her tennis shoes. She was picked up at daycare and brought to urgent care for evaluation, and the blisters were wrapped with an Ace bandage and gauze. She was then sent to the emergency department for further evaluation. Her mother had noted no recent change in her behaviors, however after she was picked up from day care she was refusing to walk and seemed uncomfortable and was crying.
She lives with both of her parents, her grandmother, her aunt and her aunt's child. She had otherwise been well except for a mild intermittent cough for 2 weeks and a fever that had resolved.
On physical examination at the time of presentation she was described as being uncomfortable and crying. Her examination was significant for large blisters (3 inches in length) on the dorsum of the right foot with erythema from the foot to the ankle, 2 large blisters on the dorsum of the left foot and on the heel with erythema, and 2 small blisters near thumb of the right hand with an area of erythema and excoriation at the distal third right finger. Laboratory values were obtained, and the differential diagnosis was thought to include burn, Staphylococcus skin syndrome, a friction burn, and multisystem inflammatory syndrome in children (MISC).
She was subsequently admitted to the hospital for concern of possible non-accidental trauma with burns, and for further evaluation and treatment. The blisters were treated with mupirocin, Aquaphor, and a Kerlix wrap, and intravenous fluids were given. A skeletal survey was done and was negative. Dermatology was consulted to evaluate for possible causes for these skin lesions, and cultures of the wounds were sent. Preliminary results of the cultures showed gram-positive cocci in pairs and the culture yielded no growth. Social work was also consulted as well as child protective services. Her lesions improved over time, and a safe discharge plan was developed with the patient's aunt, and teaching was provided. She was sent home with her aunt, with follow-up as an outpatient.
The medical necessity for the inpatient hospitalization is under review.

The requested health service/treatment of inpatient emergency admission was medically necessary for this patient.
This is a patient who presented with blisters on both feet and her hand of unclear etiology. She was appropriately evaluated promptly in the emergency department, and the dermatology specialist felt that the lesions were likely consistent with burns. She therefore required immediate evaluation for possible nonaccidental trauma as well as ongoing wound care. Discharge to home at that time would not have been considered a safe plan.
She received a full evaluation as required with appropriate specialist consultation, and child protective evaluation developed a safe discharge plan with her aunt.
Hospitalization is indicated for children with possible non-accidental trauma when the ongoing safety of the child remains a concern. Physical findings of intentional burns include scalds or blisters in children younger than 5 years of age that do not fit with a proposed injury. This patient had blisters on her feet and hand that were thought to be consistent with burns and for which no clear etiology was presented. Therefore, she required hospital admission for a complete evaluation, treatment, and development of a safe discharge plan.