Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/ Infection/ Infection in leg
Treatment: Inpatient Hospital/ Inpatient hospital admission
The health plan has denied the requested treatment, inpatient hospital admission, as not medically necessary. The health plan's determination is upheld.

The patient is a male with a medical history of diabetes mellitus, hyperlipidemia, hypertension, and gout. He presented to the emergency room (ER) with complaints of swelling, redness, and pain on the left medial side of his knee which had been present for the past three days. The patient reported a previous episode of cellulitis requiring admission and treatment with Linezolid on three occasions over the past three years when he was in prison. There was no history of trauma, fever, or chills. Additionally, the patient reported decreased urine output for a couple of days and noticed that his urine was darker than usual. He denied experiencing dysuria or hematuria. In the ER, the patient received one dose of Vancomycin and was subsequently admitted to the medicine service for cellulitis. Blood cultures were obtained. Following the patient's admission to the hospital for cellulitis in the left lower extremity, an infectious disease service consultation was requested. Additionally, a bilateral lower extremity venous duplex ultrasound was performed to evaluate the extent of the swelling and inflammation. During the hospital stay, the patient was evaluated by the general surgery service, who recommended a computed tomography (CT) scan of the left lower extremity with contrast. However, the patient declined contrast administration, and the CT scan was performed without contrast. The results revealed findings consistent with possible cellulitis. The patient received treatment with intravenous antibiotics, including ceftriaxone, throughout the hospital stay. He remained afebrile, and his white blood cell count showed a downward trend. Subsequently, the patient's antibiotic regimen was transitioned to oral cephalexin to complete a 10-day course. The patient's condition improved sufficiently to allow for a transition to outpatient care.

At issue is the medical necessity an Inpatient hospital stay.
I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

In general, admission at the acute inpatient level of care is indicated for patients with cellulitis that failed outpatient therapy, in cases of limb-threatening infection, or rapid progression of the infection that necessitated high-intensity monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus or liver cirrhosis. The patient's hemoglobin A1c was 6.9, which was at the goal for patients with diabetes.

The review of the medical records did not show evidence that the patient had any of the circumstances justifying admission at the acute inpatient level of care for the treatment of cellulitis. He had likely mild dehydration along with cellulitis. However, the dehydration resolved within the first day of the hospitalization with normalization of creatinine levels. Admission for a short period was reasonable to ensure a response to antibiotics and in order to decide about antibiotic treatment after discharge, but an inpatient level of care was not warranted. Overall, this patient remained in stable clinical condition, responded to treatment very quickly, and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.