Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis Right Leg
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay. 
The health plan's determination is upheld.

This is the case of a female with a past medical history of hypertension, anemia, obesity, and fibroids, who presented to the emergency department with right leg swelling with redness and associated headache, fever, vomiting, and dizziness.
On presentation, she was febrile to 39.1C., with a blood pressure of 133/79 millimeters of mercury (mmHg), a heart rate of 78 beats per minute (bpm), a respiratory rate of 18/minute, and with an oxygen saturation of 99% on room air. Exam otherwise noted right lower extremity redness with warmth and swelling up to the mid-shin and dry cracked skin of the toes. Labs resulted with a white blood cell count (WBC) of 18.2, a hemoglobin (HGB) of 12.6, platelets of 187, a sodium of 138, a potassium of 3.8, a blood urea nitrogen (BUN) of 10, a creatinine of 0.47, and liver function tests within normal limits. A chest x-ray and electrocardiogram showed nothing concerning. The patient was given Vancomycin and Ceftriaxone in the emergency department in addition to intravenous (IV) fluids. She was subsequently brought into the hospital with concern for cellulitis of the right lower extremity and plans for ongoing IV Vancomycin and Ceftriaxone, a duplex of the lower extremity to rule out deep vein thrombosis and follow up blood cultures.

I uphold, in whole, the health plan's determination of medical necessity.

No, inpatient level of care was not medically necessary. As previously noted, this patient presenting with cellulitis with accompanying fever, vomiting, and leukocytosis was appropriate to bring into the hospital for IV antibiotics, but it appears to have been safe to treat with observation services with IV antibiotics and clinical monitoring without a medical necessity for inpatient services.
This is a patient who presented with right lower extremity cellulitis with accompanying systemic symptoms of fever, nausea, and vomiting. She was certainly appropriate to bring into the hospital in the setting of having systemic symptoms and for monitoring of her response to IV antibiotics. It is noted, however, that she responded quickly to IV antibiotics with normalization of her WBC by the next day and without ongoing vomiting, and with the patient's fevers resolved in less than 48 hours. It is further noted that she did not have any high-risk features on presentation placing her at high risk of failure to respond to IV antibiotics quickly or complicated infection (no immunocompromise, prior failure of IV antibiotics, known history of methicillin-resistant staphylococcus aureus (MRSA), concomitant abscess or necrotizing fasciitis, altered mental status, tachypnea on presentation, etc.), and infectious disease assessment was that she had a "straight forward" cellulitis. Though concern for sepsis was expressed by the emergency room physician and the admitting physician, it is also noted that her sepsis related organ failure assessment (qSOFA) score was 0 on presentation placing her at low risk of significant complications from sepsis. Given her presentation and rapid clinical improvement, she appears safe to have been treated with observation services with IV antibiotics and clinical monitoring. Inpatient level of care was not medically necessary.