Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied an Inpatient Hospital Stay.
The determination is upheld.


The patient presented to the hospital with a 2-week history of a bump lesion on the left hand. Reportedly, it started as a raised lesion that was approximately 2 centimeters (cm) in diameter. The patient drained the lesion himself and noticed pus. Three days before his presentation he noticed redness, swelling, and warmth in the left hand. Apparently, the patient was unable to make a fist because of the pain in his hand. The patient noted chills but denied a fever, loss of sensation, or numbness in his hand.
At the time of the initial evaluation, the patient was afebrile, his heart rate was 71 beats per minute (bpm), respiratory rate was 18, blood pressure 108/61, and oxygen saturation 99% on room air. The patient appeared to be well developed, well-groomed, and well-nourished. His respiratory exam was unremarkable. On the cardiac exam, the patient had a regular heart rate and rhythm, no rubs. He had erythema, swelling, and tenderness to palpation in the left hand.
The patient was admitted to the hospital with a diagnosis of cellulitis of the left wrist. Reportedly, the x-ray of the left hand demonstrated soft tissue swelling in the dorsum of the hand consistent with cellulitis. The patient received treatment with intravenous Vancomycin.
Another clinical diagnosis was acute kidney injury. It was reported that the patient's creatinine was 1.6, however, the baseline creatinine was unknown.
He was seen by hand/plastic surgery and was diagnosed with a left wrist abscess. He underwent a bedside incision and drainage (I&D) procedure that he tolerated well.
He spiked a fever, therefore 2 sets of blood cultures were sent. At that time, the patient remained hemodynamically stable. The following day the patient remained afebrile and hemodynamically stable.
The patient was reevaluated by plastic surgery. It was noted that the patient's hand was less tender to palpation. The patient was recommended for local wound care. The preliminary results from the wound culture were reported as gram-positive cocci in pairs.
The patient refused to wait for the final culture results and elected to leave the hospital against medical advice (AMA). He still received a prescription for an oral antibiotic. At issue is the medical necessity of an inpatient stay.

Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care. This patient presented to the hospital with a wrist abscess and cellulitis. He underwent an I&D procedure that was done at the bedside and did not require general anesthesia. At the time of admission, the patient was afebrile and hemodynamically stable.
Except for the one episode of a fever, the patient was afebrile and hemodynamically stable. His abscess and cellulitis did not lead to sepsis.
Even though the patient had a mild elevation of creatinine, his baseline creatinine was unknown. Regardless, the mild elevation of the creatinine level was not consistent with the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury definition of acute kidney injury (increase in the serum creatinine value of greater than or equal to 0.3 milligrams per deciliter (mg/dL) in 48 hours, increase in serum creatinine of greater than or equal 1.5 times baseline within the prior 7 days, urine volume less than (<) 0.5 milliliters (mL) /kilogram (kg)/hour for 6 hours) and could have been treated at a lower level of care. Reportedly, the patient responded to treatment with intravenous fluids very quickly with improvement in the creatinine level.
The review of the medical records demonstrated that the patient was not immunocompromised. There was no evidence that the patient had unstable concomitant medical conditions that would require admission at the acute inpatient level of care. There was no evidence that the pain was uncontrolled and the patient required administration of parenteral pain medications frequently. The patient denied any nausea or vomiting and was able to tolerate oral pain medications. He underwent a bedside I&D procedure, which in general did not require admission at an acute inpatient level of care.
Taking into consideration all of this information, there was no overwhelming evidence that either the severity of the patient's condition or the complexity of the services provided rose to the level of acute inpatient care. Care could have been provided at a lower level which would include administration of intravenous fluids and intravenous antibiotics while waiting for the culture results in order to determine the antibiotic regimen after discharge.