Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders-Cellulitis
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned in part the health plan's determination.

This pediatric patient was brought to the emergency room with a fever and right thigh rash that mom first noticed about twelve hours prior to arrival in the emergency department. When he awoke, mom noticed the redness had enlarged and she came to the emergency room that afternoon. At triage, he was in no pain with a temperature of 98.1 degrees Fahrenheit and normal vital signs. He is described in the ED (emergency department) physician's note as in no distress with a normal exam except for a 10 x 6 centimeter (cm) well-demarcated rash on the right lateral hip, extending close to the genitals with a central 1x1 cm (centimeter) punctuate lesion in the center of the rash. The ED (emergency department) physician noted the elevated white blood cell count (WBC) (20), and that the rash was not tender, the patient did not appear toxic, that there was a low suspicion for necrotizing infection. Patient was given intravenous clindamycin in the ED (emergency department). Given the "rapid spread and proximity to genitalia," the patient was admitted for further intravenous antibiotics. On arrival to pediatric floor, the vital signs were normal, and the exam was unchanged; he still appeared completely well in general and had the 10 x 6 rash.
A progress note that same evening describes him continuing to be afebrile, sitting in bed, eating dinner, appearing well. He is continued on intravenous antibiotics. The next day's progress note, has the same "interval history/24-hour events" as the previous day note about the rash "improving, less erythematous, not warm, not tender, improving with antibiotics." This physical exam does document an erythematous area along the right lateral upper thigh with some fluid drainage. His clindamycin was changed from intravenous (IV) to oral and he was discharged home. The health plan denied acute inpatient hospitalization, which is the subject of this review.

The first day was medically necessary. Thereafter, inpatient hospitalization was not medically necessary.
The patient presented with what was described as a fairly rapidly expanding cellulitis with a central punctum, without fever or toxicity. The concern in the emergency department was not for a necrotizing process, but for an expanding cellulitis that was encroaching on the genitals. The differential diagnosis, in addition to the bacterial cellulitis suspected by the admitting and treating physicians (who suspected methicillin-resistant staphylococcus aureus) included an envenomation, that is a sting or bite that represented the central punctum with surrounding and expanding erythema from a toxic rather than infectious process. Either way, given the uncertainty about the next 12 hours, it was reasonable and necessary to initially admit to the hospital for intravenous antibiotics. By the next hospital day, however, the notes indicate the patient was doing well. No fever, no toxicity, and no further expansion of the lesion-in fact, it was already receding, potentially in response to the antibiotics. Clindamycin has the same bioavailability orally as intravenously. In a patient who is taking fluids orally and who is otherwise well and non-toxic, there is no advantage to giving the medication intravenously as opposed to orally. It was reasonable to initiate intravenous treatment for the first hospital day, but once the patient showed clear improvement as opposed to lack of improvement or worsening, there was no reason to continue intravenous antibiotics. The patient could have been treated at a lower level of care on oral antibiotics with outpatient follow up. (Yes, the patient did develop some serosanguinous drainage from the cellulitis site-this is common and not a sign of worsening or a reason to be at an inpatient level of care.)