Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries - Animal bite.
Treatment: Inpatient Hospital.
The insurer denied Acute Inpatient Admission.
The denial is overturned. 

The patient is a female with a past medical history significant for bipolar disorder who presented to the emergency department due to an animal bite and edema surrounding the affected area. The patient reported being bitten by a cat one day before her presentation. She subsequently developed swelling and redness on the dorsum of the left hand. She noticed worsening swelling with associated pain but no discharge. The review of systems was also positive for swelling in the lower extremities, which was intermittent. The patient reported a history of peripheral neuropathy for which she took Elavil. She denied fever or chills. In the emergency department, the patient received treatment with intravenous antibiotics.
Laboratory evaluation revealed that the white blood cell count was 8.6, hemoglobin was 13.9, hematocrit was 40, and platelets were 228. Sodium was 139, potassium was 3.6, chloride was 100, bicarbonate was 32, blood urea nitrogen (BUN) was 12, creatinine was 0.6, and glucose was 126. Her creatine phosphokinase (CPK) was 65, and lactic acid was 1.2. X-ray of the left hand showed no fracture or radiopaque foreign body.
The patient was admitted to the hospital with a diagnosis of left-hand cellulitis due to a cat bite. Bilateral lower extremity venous duplex ultrasound was ordered to rule out a deep vein thrombosis (DVT). 
As a result of the treatment with intravenous antibiotics, the redness and swelling in the left hand improved and the patient was transitioned to a combination of oral antibiotics that included Augmentin and doxycycline. 
At issue is the medical necessity of Acute Inpatient Admission.

The health plan's determination of medical necessity is overturned in whole.

Yes, the requested health service/treatment of Acute Inpatient Admission was medically necessary for this patient.
The patient presented to the hospital with deep wounds due to a cat bite. The patient described rapidly progressive symptoms including swelling that interfered with normal movements in the left arm. Therefore, admission for the administration of intravenous antibiotics, close monitoring of clinical response, and neurovascular checks was necessary and generally performed in inpatient settings. A small puncture wound, particularly from a cat bite, may involve significant injury to the tendon, joint capsule, or articular cartilage. Animal bites usually contain multiple potential pathogens, including Pasteurella multocida (particularly in cat bites), staphylococci, streptococci, and anaerobes. Treatment of infected bite wounds of the hand includes surgical debridement, with the wound left open, and antibiotics. Although treatment of infected wound bites might be started with the administration of oral antibiotics, based on the history in this clinical case, the patient had rapidly progressive symptoms, therefore administration of intravenous antibiotics while doing neurovascular checks was justified. In fact, even after administration of intravenous antibiotics right after admission, the patient still had significant swelling, erythema, tenderness to palpation, and difficulties moving the fingers. According to the nationally accepted standards of care, if the clinical presentation is judged to require the intensity of patient's monitoring including progression of the infection, this could not be provided at other than the inpatient level of care. This accurately reflects the circumstances in this clinical case.
Therefore, the requested health service/treatment of Acute Inpatient Admission was medically necessary.