Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Hospital Admission
The health plan denied: Hospital Admission
The determination is: Overturned

The patient is a male with a past medical history of coronary artery disease and peripheral vascular disease who presented to the emergency department (ED) with complaints of bilateral leg and foot pain. In the ED, he underwent a computed tomography angiogram of the abdomen and pelvis to evaluate the peripheral vascular disease. However, it was noted that radiographic evidence was consistent with acute cholecystitis incidentally discovered during the imaging.
Consultations were made to the general surgery and interventional radiology teams. The general surgery team recommended the placement of a cholecystostomy tube (c-tube), while the interventional radiology team suggested monitoring the patient's clinical improvement with medical management before considering a c-tube. The patient was started on vancomycin and Zosyn for cellulitis, and repeat laboratory tests were pending. However, the patient refused to have blood drawn.
On physical examination, the patient appeared elderly, was screaming, and attempted to sit up in bed. The examination revealed dry blood on the bottom lip, poor dentition, and a well-healed scar on the frontal skull. A cardiac examination revealed normal heart sounds without appreciable murmurs. The patient was breathing comfortably on room air, and the abdomen was soft and non-tender. The skin on the upper and lower extremities felt warm, and no jaundice was observed. Neurologically, the patient was alert and oriented to person, place, and time, with spontaneous movement of the extremities.
The gallbladder ultrasound revealed a non-distended gallbladder with circumferential mural edematous thickening and gallstones. The appearance of the gallbladder wall was consistent with edematous changes secondary to an underlying process, such as liver disease or other coexisting abnormalities. The findings were not typical for acute calculous cholecystitis, and there was no biliary ductal dilatation.
Consequently, the patient was admitted to the hospital with a diagnosis of acute cholecystitis and bilateral lower extremity pain. The patient received treatment with intravenous (IV) antibiotics for acute cholecystitis. It was also suspected that the patient could have bilateral lower extremity pain, which was suspected to be related to acute cellulitis for which the treatment with antibiotics was already initiated. Subsequently, it was determined that the patient was unlikely to have cellulitis of the lower extremities, therefore treatment with vancomycin was discontinued. The patient still remained on Zosyn due to acute cholecystitis.
During the hospital stay, the patient continued to receive treatment with Zosyn for acute cholecystitis. He completed a 7-day course of antibiotics. His fever resolved, and the patient was transitioned to outpatient care.
At issue is the medical necessity of the hospital admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of a hospital admission was medically necessary for this patient. This elderly individual with acute cholecystitis should have received treatment at the acute inpatient level of care due to unclear compliance with medical treatment, the need for close monitoring, and the administration of IV antibiotics to ensure the resolution of acute cholecystitis. Generally speaking, this patient was at high risk for adverse outcomes. Therefore, providing treatment with IV antibiotics while in the hospital was the right decision, to ensure the resolution of his acute cholecystitis and a smooth transition to outpatient care.