Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left thigh pain, difficulty ambulating
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient has a history of ESRD (end-stage renal disease), HTN (hypertension), DM (diabetes mellitus), CHF (congestive heart failure), and right thigh abscess. He presented with left thigh pain and difficulty ambulating. He was on PO (oral) clindamycin. He had missed dialysis for seven to ten days secondary to LE (lower extremity) pain/ambulation problems, and the dialysis center would not take him until he received a full evaluation. He had dialysis in the ED two days prior. He had dyspnea and vomiting prior to coming to the hospital.
In the ER, the patient's vitals were as follows: T (temperature) - 98.0, P (pulse) - 77, RR (respiration rate) - 18, BP (blood pressure) - 160/111. On general examination, the patient was NAD (no acute distress). Examination of his CVS (cardiovascular system), chest, and abdomen were normal. Examination of his skin revealed warm, dry, no rash. No bruising, no cyanosis. Right thigh- seven cm (centimeter) incision, smells sour, no erythema or tenderness around wound. No signs of cellulitis. Psych evaluation revealed him to be slow to respond and slow moving.
In the ER, the patient was noted to have hyperkalemia secondary to missed dialysis. In addition, he had other signs and symptoms that were concerning, These included his slow response, slow movement, difficulty ambulation, multiple LE wounds, transaminitis, as well as no long term plan for dialysis. The nephrologist recommended MWF dialysis, but the only way to obtain this would have been an ER visit three time a week, since the dialysis center would not take him until he was fully evaluated.  Finally, he had a + MRSA culture in the right thigh from several days prior, and the wound that had an odor (but no other signs of cellulitis).  
In the ER, the patient received IV calcium gluconate for hyperkalemia, as well as hemodialysis, and was admitted. PT (physical therapy) evaluation after one day of inpatient treatment found impairments, with decreased ROM (range of motion) and strength, and rehab at a facility. The patient was evaluated by wound care, who suspected a wound infection and ordered imaging. The patient had bleeding from LE wounds on ambulation.  CT scan demonstrated right thigh changes around incision site c/w (consistent with) wound infection. Infectious diseases consultation recommended IV vancomycin for MRSA infection. Over the next several days, the cellulitis improved, and once arrangements were made for outpatient dialysis and safe discharge, the patient was discharged home.

This patient should have had inpatient admission and treatment for many reasons:
1) The patient had no practical way to obtain three times weekly hemodialysis (HD). As he could not obtain HD as an outpatient, he would have had to come to the ER three times per week, which is not appropriate, and would incur substantial burden.
2) The patient had worrisome signs related to ESRD and uremia. The patient was noted to have hyperkalemia, slowing of thought and movement.  Urgent dialysis and admission were necessary.
3) Outpatient management would not have addressed the underlying issue of LE pain, which led to the missed dialysis in the first place. Because of the soft tissue infection, which was thought to be more than superficial on CT, and the fact that MRSA was obtained, inpatient evaluation, and IV treatment were necessary and supported by the Infectious Diseases Society of America guidelines (1)
4) Difficulty in ambulation and excessive bleeding from wounds are also additional reasons for inpatient admission and evaluation.
Thus, this admission was warranted, supported by standard of care and IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, fall injury, uremia, or death.