Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left leg ulcer

Treatment: Inpatient hospital services

 The insurer denied coverage for inpatient hospital services. The denial was upheld.

This patient is a female who presented to the emergency department complaining of pain to the left shin. The documentation detailed the patient had a left leg ulcer for approximately 2 to 3 months.  She does have a history to include diabetes as well as left extremity venous stasis ulcer and lymphedema.  She stated that the wound has become acutely more painful and did undergo 10 days of antibiotics at the beginning of the year. Upon physical examination there was a 3 x 3 cm ulcer on the anterior shin on the left leg with mild whitish discharge.  There was tenderness to palpation overlying the ulcer with 2+ edema to the bilateral extremities.  The physician detailed the patient should undergo laboratory studies and be admitted for treatment with antibiotics.  It was recommended the patient be treated with Flagyl, as well as, ceftriaxone and vancomycin.  The laboratory studies revealed a normal white blood cell count 8.5 with no significant abnormalities noted.  The patient's ESR was also noted to be normal.  An x-ray revealed diffuse soft tissue swelling with no acute fracture or dislocation.  There was no cortical destruction or periosteal reaction.  There was no evidence of osteomyelitis.  The documentation detailed she was admitted with the diagnosis of cellulitis.  The recommendation was made for cleansing the wound, as well as, applying a dressing and medication.  The documentation indicated she did not have any significant abnormalities or acute events during the hospital stay.  The patient was discharged the following day given the lack of instabilities.

According to current literature a patient may be admitted to inpatient services with a diagnosis of cellulitis when there is evidence that there has been a failure of outpatient therapy as indicated by a progression or no improvement after adequate trial of treatment.  There must be documentation supporting an adequate antibiotic regimen with the use of a first-generation cephalosporin, antistaphylococcal penicillin, resistant organism or regimen, or penicillin allergic patient regimen.  Additionally, there must be documentation that outpatient intravenous therapy is not appropriate or there is evidence the patient has a limb threatening infection or high risk for morbid conditions such as very poorly controlled diabetes or immunosuppression.  Within the documentation the above is not present.  It was noted that the patient presented earlier this year complaining of worsening pain to the shin related to a slow healing ulcer.  However, the patient had a normal white blood cell count and did not have documentation supporting the progression or lack of improvement after an adequate trial during observation.  Furthermore, there is a lack of documentation supporting an adequate antibiotic regimen and indication that the patient cannot participate in outpatient intravenous therapy, has very poorly controlled diabetes or is immunosuppressed.  Therefore, given all of the above the requested inpatient hospital stay was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services at the acute inpatient level of care is not substantiated.  The insurer's denial is upheld.