Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left foot cellulitis.
Treatment:  Inpatient admission.

The insurer denied the Inpatient admission.  The denial is upheld.

The patient is an adult male with diabetes mellitus. He was admitted to the hospital for left foot cellulitis. He did not have a wound on the foot. He had evidence of nail fungus infection. 

The patient's vital signs were normal. He was afebrile. Clinical examination was normal. There was no described crepitus or violaceous discoloration. The cellulitis was limited to the foot and did not go up to the leg. The patient did not have necrosis of skin or subcutaneous tissue documented on examination. His pulses were normal, and he did not have compartment syndrome. He did not have any abnormalities on routine blood tests including chemistry panel and complete blood count. MRI (magnetic resonance imaging) was performed and did not demonstrate any osteomyelitis. The patient was given intravenous antibiotics and stayed in the hospital. He was discharged on oral medications for cellulitis. Outpatient follow up with Podiatry was arranged. The patient did not have intractable symptoms, such as nausea or vomiting, and was able to take oral food and fluids. He was able to take oral medications. There were no unstable comorbid conditions. The health plan's reason for denial of coverage of the inpatient admission is that the patient did not have abnormal vital signs, immunocompromised status, compartment syndrome, compromised left lower extremity or necrotizing infection. He did not have systemic symptoms or signs. No sepsis was present. The patient did not receive an adequate course of outpatient antibiotics at sufficient dose documented in the medical chart. The patient's blood culture was negative. The reason for appeal is that the patient was treated with IV (intravenous) antibiotics and had an MRI (magnetic resonance imaging) with infectious disease consultation, routine labs and oral home medications. The treating practitioner evaluated him and all the complexities of his management including peripheral arterial disease. They posit that retrospective review can be inaccurate.

The Inpatient admission was not medically necessary.

Inpatient hospitalization is medically necessary to treat an acute and severe medical condition that cannot be treated in the outpatient setting and requires the intensive resources of inpatient hospital treatment. This patient did not have an ulcer or wound on the foot. Cellulitis did not extend to the leg or thigh. He did not have crepitus or violaceous discoloration, blister formation or compartment syndrome. He did not have sepsis or positive blood culture. His routine laboratory data were normal or near normal and vital signs were normal. He was on room air and not toxic appearing. This signifies that he had a low risk, non-acute, low severity condition that did not require inpatient hospitalization. Excellent oral antibiotics with high bio availability are available for the treatment of cellulitis. The patient did not have uncontrolled diabetes mellitus or active peripheral arterial disease with foot ischemia documented. He did not have any immune compromised. He did not have necrotizing infection or systemic sepsis.