Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Medial Thigh Abscess. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history significant for a cerebrovascular accident (CVA) who presented to the hospital with a left medial thigh abscess. The patient was traveling when he felt an insect bite on his inner thigh several weeks before his presentation. He said that it felt itchy and was scratching the area. Subsequently, he noticed redness in the area that was associated with swelling. He endorsed a tiny black scab over the area that he removed, but the scab subsequently returned. 
Several days before his presentation, he noticed night sweats and chills associated with a mild headache. At the same time, the patient denied nausea, vomiting, myalgias, arthralgias, other elements of skin rash, or altered mental status. He took ampicillin for two days without any improvement and therefore decided to come to the emergency room. Upon initial evaluation in the emergency department, the patient was afebrile. 
While in the emergency department, the patient underwent incision and drainage (I&D) of the area, and the cultures were sent. His blood pressure was 108/63, heart rate 64 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 99% on room air. 
At the time of the initial evaluation, the patient was in no acute distress.
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. 
There was an 8 x 8 centimeter (cm) area of induration and erythema. The wound was packed with gauze. 
Laboratory evaluation revealed that the white blood cell count was 9.9, hemoglobin 13.6, hematocrit 41.3, and platelets 244. The sodium was 136, potassium 4.2, chloride 104, bicarbonate 24, blood urea nitrogen (BUN) 21, creatinine 0.93, and glucose 87. Liver function tests were unremarkable, lipase was 93. 
The patient was admitted to the hospital with a diagnosis of left thigh abscess and skin and soft tissue infection. The patient initially received treatment with an intravenous antibiotic, Unasyn, but subsequently was transitioned to an oral antibiotic, Doxycycline. The patient continued to receive treatment with Tylenol and ibuprofen for pain control. Considering the previous history of a CVA, the patient received Aspirin and Atorvastatin.
Since the patient's clinical condition continued to improve, he was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. 
In general, admission at the acute inpatient level of care is indicated for patients with cellulitis that failed outpatient therapy, in cases of limb-threatening infection, or rapid progression of the infection that necessitated high-intensity monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus, or liver cirrhosis. 
Admission at the acute inpatient level of care is also indicated for patients with cellulitis and bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection or oral cellulitis, or when patients need a surgical procedure not amenable to outpatient or emergency department care, cases of cutaneous gangrene, or when patients have severe pain requiring acute inpatient management, inability to maintain oral hydration, in cases of compartment syndrome, or some other conditions that were not relevant to this clinical case. 
The review of the medical records did not show evidence that the patient had any of the circumstances justifying admission at the acute inpatient level of care for treatment of cellulitis. 
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care, rather than admission to an inpatient level of care. 
Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was very short. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.