Diagnosis: Hand Infection
Treatment: Inpatient admission
The insurer denied inpatient admission.
The health plan's determination is upheld.

This patient is a female house cleaner with a past medical history (PMH) of vertigo who presented to the emergency room complaining of severe left thumb pain with decreased ability to move her finger. She reported worsening left thumb pain, redness and swelling for 2 days at an intensity of 10/10 associated with decreased ability to move her finger. She reported no history of trauma or laceration to her finger while working as a house cleaner. On assessment, she was tachycardic with a heart rate of 101, she had "erythema from base of thumb distally, circumferentially...tenderness of flexor surface from distal to proximal interphalangeal joints (PIP) to pulp, tenderness of proximal and distal segments dorsally, minimal flexion of distal interphalangeal (DIP) and PIP secondary to pain, decreased passive range of motion (ROM), unable to fully-oppose, pain in volar and dorsal sides with passive extension."
Her laboratory workup was significant for a white blood cell count (WBC) at 14.44, neutrophil absolute (Abs) at 9.98, and lymphocyte at 18.6. Given her 2 days of worsening left thumb pain associated with redness and swelling, there were concerns for possible flexor tenosynovitis versus (vs) cellulitis. She was admitted as an inpatient for dual intravenous (IV) antibiotics, strict hand elevation, pain control and management as well as serial laboratory workup.
The patient's pain and swelling did not improve. She underwent an incision and drainage (I&D) of dorsal fluctuance of her left thumb. Post procedure, her left hand was placed in a betadine/soap soak wherein a dressing was applied. She continued to receive dual IV antibiotics, she was maintained on strict hand elevation in stockinette as well as pain control management. Her symptoms improved following incision and drainage and she was discharged.
At issue is the medical necessity of inpatient admission.

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

The requested health service/treatment of inpatient admission is not medically necessary for this patient.
This patient was medically stable and needed only antibiotics and incision and drainage. She was ready for home within 24 hours of incision and drainage. The patient had a hand infection that responded to appropriate treatment with antibiotics and surgical drainage. She was otherwise clinically stable and not in need of intensive care unit treatment or constant nurse monitoring per the documentation. In this case, the patient responded rapidly to the interventions and was able to be safely transitioned to home. Inpatient admission was not required because the patient responded rapidly and appropriately to treatment interventions.
Therefore, the requested health service/treatment of inpatient admission was not medically necessary.