Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection of Right Foot.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.
	
According to the documentation submitted, this is a male with a history of diabetes and hypertension.  The patient arrived at the emergency room (ER) and was admitted. As per the emergency department (ED) triage note the patient came to the ER with complaints of right foot pain and swelling. The patient reported that a plate fell down on his foot and cut his foot 15 to 20 days ago. The patient reported that the scratch did not heal but became bigger. He was given ampicillin 1000 mg (milligrams) with another medication that he could not recall. He needed more medication for his foot because he finished the ampicillin. Exam revealed bandage to right foot and infected wound 2 cm (centimeters) x 0.1 cm. He had pedal pulses bilaterally. The provider noted that the patient took 8 to 9 doses and used the rest as a paste to apply to the cut. He complained now that the cut opened up and is painful and appeared infected. He denied fever, chills. The provider noted he was afebrile with a 3 cm laceration draining serosanguinous fluid. The plan was right foot Xray, antibiotics, and clean wound and reassess. Right foot X ray noted no fracture or foreign body noted. The patient was seen by surgery consult and patient was admitted to surgery service for infected foot with diabetes. White blood count (WBC) was 8.92. Surgery plan was for the patient to be admitted with antibiotics of Gentamicin and Clindamycin IV (intravenous), diabetic diet and elevate extremity.

Based upon the information provided, the inpatient admission was not medically necessary as the patient could have been treated in an observation stay. The patient had an infection of the right dorsum of the foot. He had WBC (white blood cells) of 8.9. He did not have any fever. He could have been managed with observation and discharged without an inpatient admission; and could have been sent home the following day after 23 hours of observation. He was afebrile and did not require continued inpatient care as he could have been managed only with observation care. The insurer is correct in denying the hospital admission as the patient did not meet the criteria for acute admission; he did not have an elevated WBC; his diabetes was not significantly out of control, and he did not have a fever. All of his care could have been done in an observation setting. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 25th Edition Cellulitis ORG: M-70 (ISC) Clinical Indications for Admission to Inpatient Care: Admission  is indicated for 1 or more of the following:  Hemodynamic instability; altered mental status that is severe or persistent; Failure of outpatient therapy; Limb-threatening infection;   Clinical presentation (e.g., acuity of infection, rapidity of progression) is judged to require intensity of patient monitoring (e.g. vital sign measurement, checks for infection progression) that cannot be provided at other than inpatient level of care; significant immunosuppression (e.g. long term systemic steroids, neutropenia);  Bacteremia (with a likely causative organism),  Suspected necrotizing soft tissue infection..."

Therefore, inpatient acute stay was not medically necessary and the denial is upheld. The health care plan did act reasonably and with sound medical judgment. 
 
Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.