Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male. He presented to the emergency department with complaints of erythema, warmth and pain to the left leg. The patient also had complaints of subjective fever, chills and episode of vomiting. The patient had recently been diagnosed with infection in the left leg: left leg cellulitis. The
patient was started on treatment with Doxycycline for three days and Augmentin for two days. The patient also reported a pruritic diffuse rash on his neck, which developed after he started taking Augmentin. 

The patient's evaluation in the emergency room showed following vitals: T (temperature) - 98.4, BP (blood pressure) 111/86, P (pulse) - 111, R (respiration rate) - 17, Pulse oximetry - 97%. Evaluation in the emergency room showed that the patient had full movement of his leg and normal sensation.

Venous Doppler was negative for DVT (deep venous thrombosis). Lab results were notable for leukocytosis - WBC (white blood count) was 16 K (thousand). The patient was given Vancomycin, Ceftriaxone, Benadryl, Ketorolac and IV
(intravenous) fluid in the emergency room. Augmentin was stopped. The patient was admitted to inpatient medical hospital admission for management of the cellulitis. During hospital stay, patient was treated with IV (intravenous) Clindamycin, Benadryl and topical betamethasone. During the hospital stay, the antibiotic regimen was changed to cefazolin and Vancomycin. The dose of cefazolin was later increased during the hospital stay. The patient responded to treatment, and the cellulitis improved. The patient was discharged on Day #5.

The Inpatient Admission was not medically necessary.

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 duration 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 above duration, there were no new investigations ordered / work up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital. During the above duration, 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 above duration, 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. Although patient had pain, it was not intractable, and not noted to be amenable to appropriate oral treatment. Care rendered during this time was of low intensity, routine nursing and physician monitoring. 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 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 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 above dates.