Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This male presented to the emergency department (ED) with left leg pain, swelling and redness. The patient had been seen in the emergency department the prior evening but left prior to workup. He had taken two doses of Amoxicillin from an old prescription, then came to the emergency department. His past medical history was significant for chronic back pain, chronic obstructive pulmonary disease (COPD), intravenous drug abuse (IVDA), anxiety, depression and tobacco abuse. His past surgical history (PSH) was positive for back surgery, bilateral knee surgery and left shoulder surgery. Medications included hydromorphone, Flomax, Klonopin, Morphine, Zoloft, Amitriptyline, Albuterol and Symbicort. 

At presentation, the patient's vitals were: temperature (T) 98.1, heart rate (HR) 78, respiratory rate (RR) 18 and blood pressure (B/P) 135/84.   The patient's examination showed an alert and oriented male with extensive circumferential cellulitis. The swelling had started as a pimple five days prior. Aspartate Aminotransferase (AST) Test 56. Blood Cultures drawn. CXR (chest x-ray) showed new right upper opacity as compared to prior exam.  X-ray of the left leg noted soft tissue edema of the left upper tibia and fibula. The patient was medicated with Tylenol with Codeine for pain.  Intravenous (IV) normal saline (NS) at 125 cubic centimeters per hour (cc/hour) was initiated and Vancomycin, Piperacillin and Tazobactam were administered. 

The patient was admitted for left leg cellulitis. The leg was kept elevated. Blood cultures were pending. The patient's home medications were to be continued. A nicotine patch was placed as the patient was not motivated to stop smoking despite counselling. Enoxaparin subcutaneous (SC) was initiated. Infectious disease consultation recommended a computed tomography (CT) scan of the chest and change of antibiotics to cefazolin.  Lab tests showed a white blood cell (WBC) count of 7.4 and x-ray of the tibia/fibula did not show acute pathology. 

On the night of admission, the patient was heard moaning. He claimed that he had fallen out of bed but was not hurt and did not hit his head. No physical bruises or lacerations were noted. The patient stated he regularly falls out of bed while asleep. He was seen by the doctor (MD); no interventions were ordered. The patient was continued on intravenous fluids and intravenous antibiotics (IVABS). 

Computed tomography (CT) of the chest did not show air space consolidation. It showed moderate to severe upper lobe predominant centrilobular emphysema. There was a four millimeter (mm) right upper lobe nodule. There were also chronic T5 and T8 compression fractures. A follow-up chest computed tomography in 12 months was advised. Methicillin resistant staphylococcus aureus (MRSA) was negative. 

On the following day, the patient informed the Social Worker that he wanted to sign out against medical advice (AMA). He stated that his friend was coming to pick him up in 20 minutes. The patient informed the social worker that he was a current, not a former, heroin user but refused any treatment. The risks of leaving against medical advice were discussed with the patient by the Physician. The patient verbalized understanding of all risks. He refused to wait for discharge instructions.  Prescriptions for oral antibiotics were called into a Pharmacy and the patient was aware. 

No, the proposed inpatient admission was not medically necessary. 

An inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk as based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition. 

For the duration, the patient was afebrile and had stable vital signs. 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 work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered  / work-up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital. During the above duration, the patient's diagnosis had been established clinically and based on the results of the investigations, the patient was hemodynamically stable and afebrile. For the above duration, the patient had stable vital signs and routine labs remained at baseline. The patient's temperature and other vital signs were not representative of sepsis during this time. General and systemic examination was normal or at baseline. The patient was able to eat food, drink fluids and take oral medications. Although the patient had pain, it was not intractable, and not noted to be amenable to appropriate oral treatment. No systemic findings such as high fever, shock, renal 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, the ongoing risk of deterioration was low since diagnosis had been established. 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. With a low severity of illness in the post acute phase and low intensity of interventions during this time, with relative clinical stability, lack of significant comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates. In view of these findings and generally in accordance with Milliman Care Guidelines (MCG) therefore, the ongoing inpatient level of care for the above duration was not medically necessary. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.