Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection (on left face and neck-cellulitis)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with medical history that includes hypertension, congestive heart failure, bipolar disorder, anxiety, and depression. The patient presented with left-sided facial swelling and also had difficulty with swallowing. The patient did not have difficulty with breathing. The patient had undergone laparoscopic arthroscopy of the left knee for meniscal injury earlier the same day. Vitals in the emergency room were blood pressure 92/61, pulse 89, temperature 36.5 C (Celsius), respiration 20, and pulse oximetry 96 percent on room air. Examination showed left side of face and neck with swelling and tenderness. Labs showed white blood cell count 12.5 thousand and lactate 3.4. Computed tomography (CT) of the neck soft tissue showed nonspecific left neck reaction without definitive collection or abscess. The patient was started on treatment with intravenous fluids, intravenous clindamycin, and intravenous steroids. The patient was admitted to inpatient hospital stay and also evaluated by Infectious disease consult. Follow-up labs showed white blood cell count 8 thousand and lactate 0.96. The patient did not have any difficulty swallowing, and there were no new symptoms. The patient was discharged home in view of improvement.

The inpatient admission for the above duration was not medically necessary. 

The patient presented with left side facial swelling concerning for cellulitis and was treated with intravenous antibiotics with improvement. Clinical evaluation and review of lab results do not show any findings to indicate the patient had sepsis / septic shock that may need inpatient admission for treatment. Additionally, the patient was not immunocompromised, the area of involvement in this case was not located over a prosthesis or implanted device, and the patient did not have involvement of the eye (orbit). In view of this, inpatient medical admission was not needed for the above duration. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further workup in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for workup or change in management plan in an inpatient setting. Care rendered during this time was of low intensity, routine nursing and physician monitoring. No systemic findings such as high fever, shock, renal or liver failure or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. The patient was not in acute distress and in view of these facts of the patient's clinical status, ongoing risk of deterioration was low since diagnosis had been established and the patient was responding appropriately to the treatment. The patient did not have any acute complications during this time. No high frequency, high complexity, or high-risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. The ongoing inpatient level of care for the above duration was not medically necessary.