Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Infection On Right Forearm
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who had a past medical history significant for hypertension (HTN) and benign prostatic hyperplasia (BPH). He presented to the emergency department with a chief complaint of worsening swelling, pain, warmth, and redness to his right arm. One day prior to presentation, the patient noticed an insect bite on his right arm. He self-administered Keflex by mouth (PO) (three doses of 500 milligrams [mg]) without any improvement. He continued to feel streaking up his arm with increased tightness and pain. 

Examination in the emergency room showed one central lesion with the appearance of a bug bite on his right forearm noted, surrounded by cellulitic erythematous rash. Blood cultures were sent. An x-ray of the right forearm revealed nonspecific soft tissue swelling. A urinalysis was sent. There was concern for cellulitis with lymphangitic spread. Vancomycin 1,000 mg intravenous piggyback (IVPB) was administered. On receiving vancomycin, the patient developed red-man syndrome. Benadryl 25 mg intravenous (IV) was administered. IV vancomycin was discontinued and then re-administered at a slower rate. The patient was admitted for further work up and evaluation - treatment of cellulitis Vancomycin 1,000 mg IVPB every 12 hours (q12hrs) was administered. An Infectious Disease consult was called and diagnosed the patient with right upper extremity (RUE) cellulitis in the setting of a bug bite. Outpatient parenteral antimicrobial therapy (OPAT) for IV Daptomycin 6 mg per kilogram (kg) daily for a minimum of seven days was recommended. The patient was then discharged home with instructions to follow up with OPAT the following day and his primary care physician (PCP) within one week.

No, the proposed treatment (inpatient admission) was not medically necessary.

The patient presented with examination findings consistent with cellulitis and concern for lymphangitic spread. Evaluation in the ER showed the temperature as 36.6 C, pulse 74, pulse oximetry 96%, blood pressure 128/81, and respiration 20 breaths per minute. Labs showed white blood cell (WBC) count of 10.42 and erythrocyte sedimentation rate (ESR) of 15. The patient was given Vancomycin in the emergency department with some retraction of the area of redness and swelling.

The patient did not have symptoms of fever before presentation to the ER, during the evaluation in the ER, or during the hospital stay. An x-ray of the right forearm revealed nonspecific soft tissue swelling. The patient did not have systemic manifestations of cellulitis with possible lymphangitic spread. Additionally, the patient had slight improvement in the area of redness and swelling after IV vancomycin in the ER.

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. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk is based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to consider when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition. 

The patient was afebrile and had stable vital signs. 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. Physical exam for this admission did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the hospital stay, there were no new investigations ordered/work up initiated, and there was no change in management plans that would justify/necessitate inpatient stay in the hospital. During the admission, the patient's diagnosis had been established clinically and based on the results of the investigations. The patient was hemodynamically stable and afebrile. For the stay, the patient had stable vital signs and routine labs remained at baseline. The patient's temperature and other vital signs were not representative of sepsis during this time. General and systemic examination was normal or at baseline. The patient was able to eat food, drink fluids and take oral medications. No systemic findings such as high fever, shock, renal or liver failure or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. The patient was not in acute distress and in view of these facts of the patient's clinical status, ongoing risk of deterioration was low since diagnosis had been established and the patient was responding appropriately to the treatment. The patient did not have any acute complications during this time. No high frequency, high complexity, or high-risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness in the post-acute phase 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 for the dates in question.