Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Leg Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a male who initially presented to the emergency department with concerns for a right leg wound of several weeks duration. His pertinent history included drug abuse of opiates and hypertension. His initial vital signs revealed a temperature of 37.1 degrees Celsius, heart rate (HR) 81, blood pressure (BP) 177/102, respiratory rate (RR) 18 and his peripheral capillary oxygen saturation (SpO2) was 97 percent (%) on room air. The initial examination documented a right lower extremity deep ulceration with surrounding erythema.

The initial laboratory testing revealed a white blood cell (WBC) count of 8.5, hemoglobin 14.5, platelets (Plt) 340, sodium (Na) 135, potassium 4.1, blood urea nitrogen (BUN) 12, and his creatinine was 0.86. His glucose was 108, total bilirubin 0.6, aspartate aminotransferase (AST) 20, and his alanine aminotransferase (ALT) was 13. Empiric antibiotics were initiated. The patient was placed in the hospital thereafter with an impression of an infected wound and left leg cellulitis. The treatment plan included empiric Cefazolin, wound care, and infectious disease consultation. The day after admission, the patient remained afebrile and hemodynamically stable (BP 177/96) with a normal white blood cell count. No additional scheduled anti-hypertensives were added. His home Amlodipine was continued.

There were no new issues. The wound culture grew Streptococcus pyogenes. Infectious disease was consulted and recommended oral Augmentin for 7 days and Chlorthalidone was added.

Based on the clinical documentation provided, evidence based literature and standards of care, an acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care.

In regard to cellulitis, Ramakrishnan, et al notes inpatient treatment is necessary for patients who have uncontrolled infection despite adequate outpatient antimicrobial therapy or who cannot tolerate oral antibiotics. Hospitalization is also indicated for patients who initially present with severe or complicated infections, unstable comorbid illnesses, or signs of systemic sepsis. Broad-spectrum antibiotics with proven effectiveness against gram-positive and gram-negative organisms and anaerobes should be used until pathogen-specific sensitivities are available; coverage can then be narrowed. Intravenous antibiotics should be continued until the clinical picture improves, the patient can tolerate oral intake, and drainage or debridement is completed. [1]

Clinical indications for admission to inpatient care were not met. The patient did not have a failure of outpatient therapy, a hemoglobin A1C (HbA1C) greater than (&gt;) 10%, limb-threatening infection, bacteremia, persistent altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, inability to maintain oral hydration, or severe pain requiring inpatient management. In addition, the patient did not require an associated surgical procedure [i.e. (that is), abscess drainage, debridement] not amenable to outpatient, emergency department, or observation care or any other condition, treatment, or monitoring requiring inpatient admission. [2]

The patient had a history of chronic hypertension who presented with right lower extremity cellulitis. Hypertension was noted as well as concerns for non-compliance with prior medications. There was no evidence of associated end-organ damage or significant symptoms related to high blood pressure. The treatment plan included additions and adjustments of oral anti-hypertensives. No other issues or complications were documented.

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