Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient Stay.
The insurer denied: Inpatient Stay.
The denial is: Upheld.

The patient is a female with a past medical history significant for arthritis, left hip replacement, and right knee replacement who presented to the hospital with complaints of left lower extremity redness, tenderness, and swelling. The patient stated that approximately a month ago she noticed a small red spot in the mid-shin area on the left. Approximately a week before her presentation, she noticed that the area started to spread quickly to the pretibial edema area towards the foot. The patient was seen by her primary care physician who prescribed Keflex, which she took for about a week and noticed no improvement.

There was left lower extremity tenderness, swelling, and redness in the left shin area, which was very warm to touch and very tender even on light palpation. The calf on the left side was without tenderness. The right lower extremity showed no signs of edema, redness, or tenderness. The rest of the physical exam was unremarkable.
In the hospital, the patient underwent a left lower extremity venous duplex ultrasound that demonstrated no evidence of left lower extremity deep vein thrombosis.
In the emergency department, the patient was started on intravenous Vancomycin. The admitting physician discontinued Vancomycin and started Ancef, which she received for four days. She received oral pain medications for pain control. At the time of discharge, the patient was transitioned to oral antibiotics including Amoxicillin and Doxycycline and discharged from the hospital. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested inpatient stay is not medically necessary for this patient.
Based on the nationally accepted criteria, admission at the inpatient level of care for patients with cellulitis is generally indicated in cases of cellulitis and certain cases of failure of outpatient therapy, limb-threatening infection, cases of rapid progression of the infection necessitating high intensity of patient monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus, or liver cirrhosis.
Admission at the acute inpatient level of care is also indicated for patients with cellulitis and bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection or oral cellulitis, or when patients need a surgical procedure not amenable to outpatient or emergency department care, cases of cutaneous gangrene, severe pain requiring acute inpatient management, inability to maintain oral hydration, cases of compartment syndrome, or some other circumstances that were not relevant to this clinical case.
In this clinical case, the patient had no circumstances listed above except for the failure of outpatient treatment that she received before this admission. However, there was no mention that outpatient intravenous therapy was not available or could not be arranged in a timely manner. Furthermore, the patient had no systemic signs of infection.
The patient could have been managed at a lower level of care status.