Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially presented on for a pre-planned excisional debridement of a left leg ulcer. Her pertinent history included a left leg ulcer of one year duration with debridement three weeks prior. Her additional history included coronavirus 2019 (COVID-19) positive at previous hospitalization, diabetes mellitus, anemia, and hypertension. The initial vital signs revealed a temperature of 98.4F(Fahrenheit), heart rate (HR) was 100, blood pressure (BP) was 121/72, and respiratory rate (RR) was 18. The initial examination documented the patient as alert, oriented, in no apparent distress, and with a left leg ulcer without drainage or surrounding erythema noted. 
A surgical debridement was performed without issue or complication. A chest radiograph revealed mild right perihilar and infrahilar lung infiltrates or early pneumonia. The initial impression by the medical team was a non-healing left leg ulcer status/post (s/p) debridement and early pneumonia. The treatment plan included analgesia, empiric cefazolin, intravenous fluids, arterial duplex ultrasound, and consultations. An infectious disease consultation was obtained who had an impression of left leg ulcer and recommended empiric intravenous Unasyn and a rapid plasma reagin (RPR) test. A chest x-ray (CXR) showed findings of infiltrates without fever, cough, shortness of breath, or chest pain. No recommendations were made to treat this finding.
The patient was documented as having no complaints. A diabetic diet was tolerated, and her pain was controlled with oral opiates. Vital signs found the patient to be afebrile, hemodynamically stable, and without hypoxia. The WBC (white blood cell) was 5.5. A wound vacuum-assisted closure (VAC) was noted to be draining minimal serosanguineous fluid. The surgical team recommended to continue wound VAC therapy. The treatment plan remained unchanged with continued empiric Unasyn.
Documentation noted surgery recommended outpatient follow-up in 2 weeks with a nurse visit every 3-4 days to evaluate the wound VAC dressing. The medical team was awaiting infectious disease recommendations on antibiotic therapy.
A split thickness graft was recommended and performed. The post-operative graft care was performed until the patient was discharged.
At issue is the Inpatient stay for medical necessity.

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

The requested health service/treatment of Inpatient stay was not medically necessary for this patient.
Based on the clinical documentation provided, evidence-based literature and standards of care, the acute inpatient level of care was not indicated as medically necessary for the entire admission. Clinical improvement was documented on a daily basis without issues or complications. Ten days after the initial operation, a skin grafting was recommended and performed. Following observation care, the patient was tolerating oral intake and pain was controlled with an oral regimen.
Ramakrishnan et al. note that in this particular situation intravenous antibiotics may be necessary and may be continued at home under close supervision after initiation in the hospital or emergency department. [1] Williams et al. note that outpatient parenteral antibiotic therapy (OPAT) is now a widely accepted and safe therapeutic option for carefully selected patients. Benefits include improved patient satisfaction.[2]
Therefore, the Inpatient stay was not medically necessary.