Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cellulitis.
Treatment:  Inpatient Hospital Admission.
The insurer denied Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult male with past medical history of asthma, depression, alcohol (ETOH) abuse, and hernia repair. The patient presented to the emergency room with complaints of right lower extremity pain, erythema, and warmth for two to three days. The patient also reported subjective chills and fever. The patient denied chest pain or shortness of breath. His evaluation in the emergency room showed an erythematous area covering the area from the knee to the ankle. The patient's vital signs were blood pressure (BP) 143/87, temperature (T) 101.3, and oxygen saturations (SpO2) 98 percent. Labs were notable for white blood cell (WBC) count 12, hemoglobin (Hgb) 10.9, mean corpuscular volume (MCV) low, red cell distribution width (RDW) high, and carbon dioxide (CO2) 19. Imaging was notable for x-ray of the tibia/fibula - no fracture, chest x-ray (CXR) - negative, and right lower extremity (RLE) Doppler negative for deep vein thrombosis (DVT). The patient's erythrocyte sedimentation rate (ESR) was 61 and C-reactive protein (CRP) was 187--149. Methicillin-resistant Staphylococcus aureus (MRSA) 
polymerase chain reaction was negative and methicillin-susceptible Staphylococcus aureus (MSSA) polymerase chain reaction was positive. Blood culture on day of admission had no growth to date (NGTD). The patient was admitted for cellulitis and started on treatment with intravenous antibiotics (vancomycin, ceftriaxone). The patient continued to improve and stabilized and was subsequently discharged.

The inpatient stay for the above duration was not medically necessary.

The patient presented with cellulitis and was febrile on presentation. Evaluation was consistent with cellulitis; however, clinical evaluation and lab results did not indicate presence of systemic sepsis / septic shock on presentation. X-ray of the tibia/fibula was negative for osteomyelitis or fracture and Doppler was negative for deep vein thrombosis. The patient's mental status was well maintained, and the patient was able to tolerate oral intake on presentation and subsequently. The patient had not failed antibiotic treatment as an outpatient prior to presentation to the emergency room and based on the presentation, inpatient admission was not medically necessary. The patient could have been safely and effectively managed at a lower level of care. Continued inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. 

For the duration, the patient was febrile but had stable blood pressure, pulse and oxygen saturation. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Care rendered during this time was of low intensity, routine nursing and physician monitoring. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, 
ongoing inpatient care was not medically necessary.