The patient was brought to the emergency department (ED) with a fever and a worsening buttock abscess and surrounding cellulitis despite oral cephalexin that had been prescribed the day before. The skin infection had worsened over a period of about a week during which time the child had intermittent fevers. In the ED, the temperature was 101.1 degrees Fahrenheit. The white blood cell count (WBC) was 31.1, Erythrocyte sedimentation rate (ESR) 56, and C-reactive protein (CRP) 20. The patient was admitted, sedated with intravenous (IV) medication, and the abscess was drained of 10 ml of pus, using the loop technique . Post procedure, the baby was continued on IV vancomycin; the wound continued to drain. The baby was afebrile the following day and clinically improved, so was discharged the following day on oral antibiotics. The health plan denied the acute admission. At issue is the medical necessity of an inpatient stay.
The health plan's determination is overturned. The patient had a large and expanding abscess on the buttock with expanding cellulitis with systemic signs of fever, significant leukocytosis (31,000) and elevation of inflammatory markers (CRP and ESR). This patient had a white blood cell count greater than 15,000. Moreover, he had failed outpatient oral antibiotics, so both IV antibiotics along with the surgical incision and drainage (I&D) were medically necessary. Acute criteria were met and the one day inpatient hospitalization was medically necessary.