Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis.
Treatment: Inpatient Hospital Stay.

The insurer denied the inpatient hospital stay.  The determination is overturned.

This is a male patient, who was four days status post washout of a large left thigh laceration in the operating room and wound closure, discharged on Keflex, who returned to the emergency department two days previously with signs of cellulitis. The Keflex was switched to Bactrim and Augmentin. He was brought back to the emergency department (ED) with a fever, pain, erythema extending beyond the markings drawn, and pus draining from the site. The C-reactive protein (CRP) had reduced from 1.37 to 1.29; the erythrocyte sedimentation rate (ESR) had increased from 14 to 32. The white blood cell count (WBC) was stable and normal. He received a dose of vancomycin in the emergency department (ED) and was admitted for further intravenous antibiotics for possible methicillin resistant staphylococcus (staph) aureus. The wound was reopened and irrigated, and he was started on intravenous (IV) vancomycin and piperacillin.
He had multiple episodes of non-bloody, non-bilious vomiting and abdominal pain after admission. His metabolic panel and vancomycin levels suggested vancomycin toxicity, and the dose was lowered. He was afebrile but continued to have pain and purulent discharge from the 10 centimeter (cm) wound; the vancomycin was stopped due to a suspected acute kidney injury (creatinine 1.6), and the antibiotic was changed to Zosyn along with linezolid recommended by infectious disease consultants. The acute kidney injury improved (creatinine decreased to 1.1). He was afebrile, and the erythema of the wound had not extended past the borders but had not improved. The creatinine reduced to 0.9, and the urine outpatient was normal. He was afebrile, but the consulting surgeons were concerned about the appearance of the wound, discoloration, and requested an ultrasound to evaluate for an abscess that could be drained. The patient was afebrile with a downtrending creatinine (0.7), but with continued surgical concern over the appearance of the wound. He was taken to the Pediatric Intensive Care Unit (PICU) for another open drainage procedure with procedural sedation. The treating physicians were less concerned about the appearance of the wound status post the procedure; he was afebrile with normal urine output and creatinine. He was discharged home on ciprofloxacin and linezolid. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary.

The patient had a large laceration from a metallic object that became infected despite proper wound care upon original presentation about five days before the admission being reviewed. Two days before this admission, he already had signs of a wound infection, erythema, induration, pain, discharge, and he was put on appropriate antibiotic coverage. Two days later, he had evidence of worsening, a fever and extension of the erythema beyond the original marked out borders. Admission was medically necessary to properly manage the wound infection surgically and medically. Despite the surgical drainage on admission and proper antibiotic coverage, the wound did not promptly resolve. He developed a common renal complication to the appropriate antibiotic, the vancomycin, which also required continued hospitalization. The creatinine rise to 1.6 indicated a significant acute kidney injury from the vancomycin, which required continued hospitalization, along with continued intravenous antibiotic treatment of the wound infection. The acute kidney injury improved over the next two days, but the wound did not, despite appropriate, multiple antibiotics. He required another surgical drainage procedure and could be safely discharged on two antibiotics with proper follow up.