Infectious disease
Inpatient hospital

Diagnosis: Knee injury. Treatment: Inpatient stay. The insurer denied the inpatient stay. The health plan's determination is overturned in part.

At the time of his admission, the patient was brought to an urgent care with a one day history of right knee swelling. The day before, he fell on the porch and abraded his right knee; the next day, the mom noticed the area was swollen so she brought him to the urgent care clinic, where the temperature was reportedly 101.6. Urgent care referred him to the emergency department (ED) for evaluation of possible septic arthritis. In the ED, the patient was afebrile with heart rate (HR) 132. He could bear weight on the right lower extremity and had normal range of motion of the knee joint and normal gait. His white blood cell (WBC) was 22.7 with 81% neutrophils. Erythrocyte sedimentation rate (ESR) was 28. C-reactive protein (CRP) 4.7. Plain film and computed tomography (CT) scan of the knee were normal. He was given intravenous (IV) clindamycin in the ED and hospitalized for further IV therapy.

The Milliman Care Guidelines for Pediatric Cellulitis specifically state that a white cell count of greater than 15,000 is an indication for acute inpatient care. The WBC for this patient was 22.7, therefore the acute inpatient care was appropriate for 1 day.
By the second hospital day, however, the patient was clinically well and had remained afebrile and hemodynamically stable. The infection (the pus pocket below the right kneecap) was spontaneously draining, did not require a surgical drainage procedure, and there was substantial clinical response after the first two doses of IV antibiotics in terms of reduction of erythema and tenderness. The treating physicians had determined that the patient did not clinically have a septic arthritis or any other systemic/deep infection requiring surgical management, prolonged IV antibiotics, and continued measurement of serum inflammatory markers. There was no evidence of bacteremia, sepsis, or SIRS (Systemic inflammatory response syndrome). The patient no longer met acute inpatient criteria after the first hospital day.