Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Infection
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male with a past medical history of psoriasis on Cosentyx and obesity. The patient presented to the emergency department with complaints of right thigh pain, redness, swelling and fatigue for one day. The patient stated that trace erythema started around a small psoriatic rash on the inner thigh the day before presentation to the ED (emergency department). By morning, the erythema worsened, and the area became hard and very painful. The patient also had complaints of fever (unmeasured) and chills. The patient's evaluation in the emergency department showed the following vital signs: T (temperature) - 100 Fahrenheit, Pulse 106, BP (blood pressure) 150/79, R (respiration rate) 18, Pulse oximetry - 97% (percent), BMI (body mass index) 57. The patient's review of systems was positive for chills, fatigue and fever. Examination was concerning for possible abscess and erythema of the right inner thigh. Ultrasound of the right thigh showed cellulitis with focal fluid containing collections measuring 3.9 x 3.8 x 1.6 cm (centimeters) and 0.6 x 0.6 x 0.3 cm (centimeters). CT (computed tomography) of the right thigh showed focal fluid collections seen on the prior ultrasound were not delineated on this CT (computed tomography) exam.
The patient's labs were notable for WBC (white blood count) 19.1. Covid test was positive, and he was placed on contact and droplet isolation. The patient was evaluated by general surgery, and the area was demarcated. The patient was treated with ketorolac IV (intravenous), Tylenol IV (intravenous), IV (intravenous) Zosyn, and IV (intravenous) Vancomycin. The patient was admitted inpatient for further management for right thigh cellulitis. Infectious Diseases (ID) was consulted for right thigh cellulitis and COVID and recommended Zosyn IV (intravenous) every 6 hours, and to start Clindamycin every 8 hours for cellulitis. Repeat COVID PCR (polymerase chain reaction) was planned. Follow up labs showed WBC (white blood count) 18.1. The patient was continued on IV (intravenous) antibiotics and pain medications and over the next few days. The patient stabilized and improved and was discharged on day #3.

The Inpatient Hospital Admission was medically necessary.

The patient had a past history of psoriasis - on Cosentyx and had morbid obesity. The patient presented with complaints indicative of cellulitis, and he was febrile on presentation. The patient also had positive COVID test on presentation, and labs showed leukocytosis, with WBC (white blood count) of 19 K (thousand), and ultrasound showing possible fluid collection concerning for abscess. In view of above presentation, it was clear that patient had notable comorbid conditions - psoriasis - 
on Cosentyx, which may predispose patients to infection / sepsis, and the patient also had morbid obesity. Obesity is a risk factor for severe COVID 19 disease and the patient had fever and positive COVID test on presentation in the ED (emergency department). Evaluation and treatment of such a patient would at a minimum need to ensure that patient is treated with IV (intravenous) antibiotics and also to ensure that the patient is responding to the treatment given in view of concerns for notable comorbid conditions as noted above. Admission to the hospital for treatment and to ensure adequate response was medically necessary and appropriate for this patient. If the patient had not responded to the initial treatment over the next few days, it would be reasonably correct to consider doing repeat CT (computed tomography) scan. Treatment that would ensure that all of the above is taken would require the patient to be admitted to the hospital to ensure adequate treatment is started and adequate monitoring is done and follow up investigations can be obtained as needed based on the clinical response of the patient.