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 female with a medical history of diabetes, hyperlipidemia, and melanoma currently undergoing chemotherapy every 3 weeks. She was brought into the emergency department due to generalized weakness and generalized body aches, with her legs giving out. On presentation in the emergency department (ED), her vital signs showed a temperature of 38.3, heart rate of 120, blood pressure at 119/62, and respiration rate was 19. On exam, the patient was ill-appearing, with dry mucous membranes, and a tachycardic cardiac exam. On musculoskeletal exam, she had a 12 by (x) 8 irregular nodular mass over the right lower calf and skin was slightly discolored and warmer than contralateral extremity.

Her laboratory studies showed a leukocytosis of 13.2, hemoglobin of 9.7 with a mean corpuscular volume (MCV) of 74. Her international normalized ratio (INR) was 1.35. The urinalysis showed 5-10 white blood cells with trace leukocyte esterase. A twelve-lead electrocardiogram (EKG) showed sinus tachycardia.

The patient was admitted to the hospital with a principal diagnosis of sepsis secondary to cellulitis superimposed on necrotic malignant melanoma. The patient was started on intravenous (IV) vancomycin, cefepime, and IV fluids. Infectious disease was consulted to evaluate the patient. They ordered a duplex of the lower extremity to rule out a deep vein thrombosis (DVT). General surgery was consulted for possible incision and drainage (I&D) of the abscess.

The patient was seen by infectious disease the next day, who reviewed the repeat laboratory studies showing persistent leukocytosis. On exam, the patient appeared warm to the touch, but otherwise, the exam was unchanged from the day before. The consultant recommended continuing empiric antibiotic coverage with vancomycin and ceftriaxone.

The urine culture grew out gram-positive cocci. The white blood cell count was slightly worsened. The patient decided to leave against medical advice from the hospital.

At issue is the medical necessity of the Inpatient Hospital Admission.

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

The requested health service/treatment of inpatient hospital admission is medically necessary for this patient.

This patient presented to the hospital with sepsis, with 2 possible sources, including cellulitis and a urinary tract infection (UTI). Sepsis in an immunocompromised patient can be fatal. It was reasonable, and in line with medical care standards, to admit this patient under an inpatient level of care for stabilization, treatment with IV antibiotics and IV fluids per goal-directed medical therapy based on sepsis protocol. The patient was appropriate for an inpatient level of care secondary to persistently elevated leukocytosis, persistent tachycardia, and hypotension with systolic blood pressures in the 90's. The urine culture showed gram-positive cocci growth, which required further monitoring until speciation and sensitivities became available. The patient was at risk for developing methicillin-resistant staphylococcus aureus (MRSA) sepsis, given the concurrent cellulitis and UTI.

Therefore, the requested service of inpatient hospital admission was medically necessary for this patient.