Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Infection. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male. He presented to the emergency room requesting heroin detox and also care of his foot infections. The patient reported bilateral foot pain and swelling. The patient has a past history of polysubstance abuse (heroin, cocaine and alcohol), bronchial asthma and history of infection - cellulitis of the feet in the past. The patient reported that he started noticing pain and swelling to both lower extremities and feet, prompting him to come to the ER (emergency room) for evaluation. The patient reported a similar history about 10 years ago, when he was diagnosed with infection and treated with antibiotics. 

Evaluation in the emergency room showed that the patient had erythema, lesion and rash present on his feet, but no ulcers were noted. The patient was afebrile and had stable vital signs and pulse oximetry. The patient's vital signs were as follows: Temperature: 36.7, Pulse: 79, Respiration rate: 
18, BP (blood pressure): 105/66, and SpO2 (pulse oximetry): 98 %. Initial lab results in the emergency room showed WBC (white blood count) 4.7 (Neutrophils 61.7%), ESR (erythrocyte sedimentation rate) 22. ECG (electrocardiogram) reported as cannot rule out anterior infarct, age undetermined (however the patient had no complaints of chest pain or other signs to indicate coronary ischemic event). Urine toxicology screen was positive for opiates and cocaine. The patient was admitted to inpatient medical hospital admission and treated with acetaminophen, methadone, IV (intravenous) Clindamycin. The patient was treated in the inpatient setting, but he later signed out against medical advice. 

Inpatient Medical Hospital Admission was not medically necessary. 

The treating physician's evaluation indicated a diagnosis of cellulitis of both feet, and the patient was admitted to inpatient medical hospital stay, due to concern for inability to adhere to outpatient antibiotic or pain management regimen. 
The patient was noted to have cellulitis of both feet however he did not have any findings on presentation to indicate extensive infection and sepsis with hemodynamic compromise or mental status changes that would require admission to inpatient medical hospital stay. The patient was able to tolerate oral intake, and he had not failed oral antibiotics before presentation to the emergency room. Additionally, the patient was afebrile, had stable vital signs and did not have clinical evidence of limb threatening infection. The patient also did not have high risk comorbid conditions like uncontrolled diabetes, cirrhosis, neutropenia, immunosuppression or HIV (human 
immunodeficiency virus) that may raise concerns of rapid progression of infection or inadequate response to oral antibiotic treatment. 

For the duration of the hospital stay, 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 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. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness, low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, inpatient care was not medically necessary. In view of these findings and generally in accordance with routine standard of care therefore, the ongoing inpatient level of care for the above duration was not medically necessary.