Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

This patient is a male with a past medical history of human immunodeficiency virus (HIV) (CD4 count unknown), intravenous (IV) drug use, and a history of methicillin-resistant staphylococcus aureus (MRSA) infections resistant to Bactrim, clindamycin, and doxycycline. He presented to the emergency department with right ankle swelling and redness. On presentation, he was afebrile with a heart rate of 114 then 104, blood pressure was 116/73, respiratory rate was 28, and with an oxygen saturation of 99% on room air. His exam otherwise noted limited ankle range of motion secondary to pain and swelling with compartments soft and no edema or erythema.
His labs resulted with a white blood cell count (WBC) at 9.6, Hemoglobin (HGB) was 15.3, platelets were 310, sodium was 131, potassium was 4.5, blood urea nitrogen (BUN) was 8, creatinine was 0.63 and C-reactive protein (CRP) was 99. Coronavirus 2019 (COVID-19) screening was negative. His x-rays of the ankle, foot, tibia/fibula, and knee showed no fracture or dislocation. Blood cultures were sent, and the patient was given intravenous (IV) fluids and IV Zosyn.
The patient was brought into the hospital with concerns for cellulitis in the setting of HIV and drug use and with plans for IV vancomycin and Zosyn and orthopedic surgery consultation. Orthopedics saw the patient with assessment that his exam was not consistent with septic arthritis with no further imaging or acute orthopedic intervention warranted.
The patient was transitioned from IV vancomycin and Zosyn to IV cefazolin. He was diagnosed with hepatitis C. He was noted to have ongoing ankle erythema, swelling and tenderness with decreased range of motion. An ultrasound of the ankle demonstrated cobble stoning of the subcutaneous tissue compatible with known cellulitis with no discrete organized fluid collection seen.
His vital signs had improved but he was deemed unstable for discharge given his ongoing ankle pain and concern for infection. He was felt to be unsafe for discharge with a continued need for further IV antibiotics. The patient subsequently left against medical advice.
At issue is the medical necessity of the inpatient level of care.

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

Yes, the requested health service/treatment of inpatient stay was medically necessary for this patient.
This is a patient who presented with ankle pain and concern for possible septic arthritis with associated tachycardia, tachypnea, and reduced range of motion on presentation. He was high risk for systemic infection and growth of resistant organisms given his history of IV drug use in addition to known prior growth of multi-drug resistant MRSA. He additionally had a history of HIV with CD4 count unknown, but with a potential increased risk of adverse outcome. Though initial assessment was that he did not have likely septic arthritis, there was concern that he required close monitoring on IV antibiotics given his tachycardia and tachypnea and risk of antibiotic-resistant infection or systemic complications.
While it is noted that the patient left against medical advice, records clearly indicate that he was not stable for discharge with ongoing hospital-level services of IV antibiotics and clinical monitoring of his vital signs, labs, and cellulitis required.
An inpatient stay was medically necessary for this patient.