Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

According to the documentation submitted, this is an adult with a history of polysubstance abuse, hypertension, tricuspid valve infective endocarditis, bipolar disorder, and osteomyelitis. The patient presented to the hospital with complaints of abdominal pain and leg pain. The patient was admitted with cellulitis, methicillin resistance staphylococcus aureus (MRSA) bacteremia, and thoracic osteomyelitis. The patient was treated with intravenous (IV) Daptomycin. The patient left against medical advice (AMA) before the care plan could be completed. 

The insurer has denied coverage for the continued inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient was treated for an infection in the bone. The patient did not have continued bacteria in the blood or a continued fever. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Osteomyelitis ORG: M-600 (ISC). 

The hospital is appealing. In an appeal letter it was stated that the patient presented to the Emergency Room (ER) with complaints of abdominal pain and leg pain. The patient was diagnosed with cellulitis of the right lower extremity. The patient was treated with intravenous (IV) Daptomycin. The patient was continued on IV antibiotics. The facility tried to place the patient in a skilled nursing facility (SNF) but no facility accepted the patient. The patient left AMA before the care plan could be completed. 

This patient has a past medical history significant for polysubstance abuse, hypertension, tricuspid valve infective endocarditis, bipolar disorder, and osteomyelitis who initially presented to the hospital with complaints of abdominal pain and leg pain. 

Patient was started empirically on intravenous (IV) antibiotics (daptomycin) for thoracic (T6-7) osteomyelitis/discitis and likely tricuspid valve endocarditis. Blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). The patient refused a transesophageal echocardiography (TEE) that was scheduled. Plan was for placement of intravenous access for long-term antibiotics with skilled nursing facility placement. Imaging studies continued to show residual anterior epidural abscess. Duration of antibiotic treatment was prolonged due to magnetic resonance imaging (MRI) findings. Patient left against medical advice (AMA). 

During the period in question, documentation states initial plan was to continue daptomycin for 6-weeks from blood culture clearance per Infectious Disease recommendations. Unfortunately, follow-up MRI revealed residual abscess and therefore, additional course of intravenous antibiotics were recommended. There were extenuating circumstances in this case that prohibited other options for treatment in less acute setting.    
Multiple progress notes support that patient had not been accepted to an outside facility for completion of antibiotics despite exhaustive efforts. Additionally, due to patient's history of substance abuse, undomiciled status, and general non-compliance (based on history of numerous episodes of leaving against medical advice), the patient was not a safe candidate for outpatient antibiotic treatment. It is clear that safe discharge for a potential medical emergency could not be established. Based on above findings, the patient fulfilled criteria for continued length of stay in an acute hospital setting during the period in question.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the continued inpatient admission is substantiated.