Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient admission. 
The denial is upheld in whole.

The patient is a male with past medical history of hypertension and obesity who presented to the hospital with concern for left lower extremity swelling, redness, and pain worsening over the past 5 days.
On presentation, the patient was afebrile with blood pressure (BP) 134/73, heart rate 74, respiratory rate 18, and with oxygen saturation 97% on room air. Exam otherwise noted lower extremity weeping edema with redness up to the thigh and warmth to touch. Labs resulted with WBC(White blood cells) count of 12.9, hemoglobin (HGB) of 15.5, platelets 309, sodium 138, potassium 3.4, blood urea nitrogen (BUN) 12, creatinine 0.87, glucose 158, liver function tests within normal limits, and lactic acid 3.2. Venous duplex of the lower extremities showed no evidence of deep vein thrombosis. The patient was admitted with concern for left lower extremity cellulitis complicated by sepsis with lactic acidosis, tachycardia, and lactic acidosis, and with plans for blood cultures, intravenous (IV) Ancef and vancomycin, infectious disease consultation and potassium repletion. Repeat lactic acid was 1.8
The patient remained hemodynamically stable without fever, tachycardia, hypotension, or tachypnea. Repeat WBC was 9 with potassium normalized, and the rest of his labs were unremarkable. Infectious disease saw the patient and noted that he had left leg and thigh erythema with serous drainage and skin crusting. Plan was for ongoing IV Ancef and vancomycin, wound care consult, and to follow up blood cultures.  The patient remained hemodynamically stable. WBC was 8.7. There was note that he developed redness of his face and IV vancomycin and vancomycin were discontinued in this setting. Infectious disease noted that the patient could be discharged on doxycycline. The patient was ultimately discharged. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld.

This is a patient who presented with lower extremity cellulitis initially accompanied by leukocytosis and lactic acidosis. He was certainly appropriate to admit given the extent of his cellulitis with accompanying weeping edema for ongoing monitoring of response to therapy, leukocytosis, and follow up of cultures. It is noted, however, that the patient's lactic acidosis and leukocytosis resolved quickly after admission, he remained hemodynamically stable throughout his course, and progress notes do not clearly describe his day to day progression on IV antibiotics but do suggest he was improving. The patient furthermore did not have a high risk comorbidity such as uncontrolled diabetes or other immunosuppression placing him at higher risk of systemic infection from his cellulitis or failure to respond to therapy. This patient presenting with lower extremity cellulitis with hemodynamic stability, leukocytosis and lactic acidosis that resolved quickly, and no clear high risk comorbidities increasing his risk of adverse event was appropriate for a lower level of care status in the absence of clearly documented failure to improve with initial antibiotic therapy necessitating ongoing IV antibiotic therapy in the hospital beyond a reasonable period of observation. Inpatient level of care was not medically necessary.