Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who presented to the emergency department (ED) from rehab center. The patient reported that his feet infections were not cared for properly in nursing facility and he had signed out against medical advice (AMA). Past medical history is significant for hypertension (HTN), hyperlipidemia, atrial fibrillation, type II diabetes mellitus (DM), diabetic neuropathy, methicillin-susceptible Staphylococcus aureus (MSSA) sepsis due to right foot abscess and left hallux ulcer; asthma, obstructive sleep apnea (OSA) (continuous positive airway pressure [CPAP]), morbid obesity and depression. Past surgical history included peripherally inserted central catheter (PICC) line placement. The patient underwent sharp excisional debridement down to soft tissue with application of graft and tonsillectomy.

Evaluation in the ER showed that vital signs were: 
Blood pressure (BP) 180/81, temperature (T) 98.4, pulse (P) 106, respirations (R) 21, and pulse oximetry 100% on room air (RA).  Lab results were significant for white blood cell (WBC) count 11.22, neutrophils 74.5, hemoglobin (Hgb) 8.3, hematocrit (Hct) 26.3, total protein 5.7, albumin 3.1, aspartate aminotransferase (AST) 53, estimated glomerular filtration rate (EGFR) 66.10, C-reactive protein (CRP) 18 and erythrocyte sedimentation rate (ESR) 130. X-ray of the right ankle showed bilateral malleolar soft tissue swelling and possible ulceration.  X-ray of bilateral feet noted right ankle soft tissue swelling.  Chest x-ray (CXR) noted interstitial opacities may indicate pulmonary vascular congestion. 

The patient was evaluated by Podiatry and advised treatment with Ancef and Aquacel dressing bilaterally. The patient was noted to have fever and chills and Tylenol was given. The patient was admitted and continued on intravenous (IV) Ancef. The patient was also evaluated by Endocrinology and recommended to add Lantus and lispro insulin. The patient was evaluated by Infectious Disease and recommended to continue Ancef and trend labs. Cardiology recommendation advised to continue anticoagulation and rate control; and discontinue aspirin. 

No, the proposed inpatient admission was not medically necessary.

This patient was admitted with complaints of foot infection and had vital signs showing BP 180/81, T 98.4, P 106, R 21, and pulse oximetry 100% on RA. The patient had stable vital signs except for mild tachycardia - 106/minute. The patient subsequently had temperature elevation and chills; however, the patient did not have any other findings to indicate rapid clinical instability or worsening that would necessitate inpatient admission. The patient was treated mainly with IV antibiotics and underwent evaluation by Podiatry, Infectious Disease and Cardiology but did not need any additional treatments that would necessitate inpatient admission for this patient. Patient was stabilized on IV Ancef and was discharged.

For the duration of the admission, the patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. Th 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 inpatient stay in the hospital. During the above duration, the patient's diagnosis had been established clinically and was based on the results of the investigations. The patient was hemodynamically stable. For the above duration, routine labs remained at baseline. General and systemic examination was normal or at baseline. The patient was able to eat food, drink fluids and take oral medications.  Care rendered during this time was of low intensity, routine nursing and physician monitoring. 

Although the patient was afebrile on presentation, he did have fever subsequent to presentation in the ER, but there were no other exam or lab abnormalities that would necessitate inpatient admission.   

No systemic findings such as 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, the ongoing risk of deterioration was low. 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 severity of illness and 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. In view of these findings and generally in accordance with MCG guidelines therefore, the ongoing inpatient level of care for the above duration was not medically necessary.