Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission

The denial is: Upheld

The patient was born full term and had a past history of severe eczema. The patient presented with right lower leg swelling, pain, tactile fever, and nasal congestion for one day. Two insect bites were noted on that leg by the mother. There was also a history of having fallen from the bed the previous day, and of being sick with viral symptoms, but the review of systems was otherwise negative.

In the Emergency Department (ED) vital signs were: Temperature of 102.2 degrees Fahrenheit (F) with a heart rate of 166. There was a well demarcated area of erythema on the right lower extremity with surrounding swelling, slightly warm to touch, and two smaller annular areas of erythema on the right knee. However, the size of these erythema areas is not documented. Eczema was noted on her face, arm and both legs. C-reactive protein (CRP) was very mildly elevated at 8, and the white blood cell count (WBC) was markedly elevated at 28,400. The patient had no laboratory evidence of dehydration. The patient was able to bear weight on the affected leg, and there was good capillary refill of the toes. 

A decision was made to admit and administer intravenous (IV) antibiotics, but the record is lacking in any medical-decision-making to support this plan of management. The fever may well have been from the current upper respiratory infection. At the most the child had mild cellulitis, if there indeed was a soft tissue infection. The presentation could also have been from local insect bites reactions. In an ED update note it is specified that there was low concern for septic joint as she was bearing weight on that leg.

The reviewer agrees with the insurer that admission for intravenous antibiotics was not indicated. The best course of action would be to send a blood culture, and a respiratory viral panel to document any viral infection which could also explain the leukocytosis, as she was a full term baby who was well appearing, parenteral antibiotics were not indicated for this presumed infection, and she could have been safely followed as an outpatient while awaiting results of the blood culture.

Specifically with regard to cellulitis, there was no sign of hemodynamic instability, progression, or any abnormal local signs to suggest a deep tissue infection. In fact, this was most likely an insect bite allergic reaction masquerading as a mild cellulitis. The cellulitis was not progressive or severe. The patient did not have severe swelling and pain. The exam did not reveal a spreading or worsening infection or a complication such as fasciitis, myositis or abscess. 

Outpatient therapy with oral antibiotics is indicated for healthy persons with nonpurulent cellulitis if they have no evidence of systemic inflammatory response syndrome (SIRS). Inpatient therapy with parenteral antibiotics is recommended in patients with SIRS, hemodynamic instability, mental status changes, poor compliance, failure to respond to oral antibiotics, facial involvement, or immune suppression. [Reference, Stevens et al, Updated IDSA guidelines].

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is not substantiated.