Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right leg pain and swelling. 
Treatment: Inpatient admission. 
The insurer denied inpatient admission. 
The denial is overturned. 

The patient is a male teen with no significant medical history. He was referred to the ED (emergency department) by his primary care practitioner for evaluation of his right leg. He was kicked in the leg four weeks prior during a soccer game, after which he developed a small bump on his shin. Over the past week, he developed nausea, vomiting, and chills. He was seen by his primary care practitioner for worsening ankle pain, was treated with an IV (intravenous) dose of clindamycin and prescribed a course of oral clindamycin. The nausea and vomiting stopped two days later, but the area of redness continued to increase in size. The primary care practitioner marked the area that day, noting on the day of referral to the ED (emergency department) that the redness surpassed the marked area. In addition, the patient was experiencing pain with weight-bearing, ultimately refusing to ambulate because of pain. He was referred to the ED (emergency department) because of failed outpatient treatment and concern for possible sepsis. 

The patient's vital signs included temperature 97.5, heart rate 81, respiratory rate 18, and blood pressure 112/63. Examination was significant for non-toxic appearance, no apparent distress, right shin with 6 x 6 cm (centimeter) area of tender erythema and central fluctuance, no palpable subcutaneous gas, no broken skin or drainage, intact distal pulses, and non-focal neurologic exam. Laboratory evaluation revealed leukocytosis (13.4K [kilogram]), thrombocytosis (423K [kilogram]), elevated ESR (erythrocyte sedimentation rate) (47), and elevated CRP (C-reactive protein) (2.035). Plain x-rays revealed mild increased soft tissue density in the anterior lateral shin, and no signs of osteomyelitis. Bedside ultrasound revealed a fluid collection measuring at least 2 x 3 cm (centimeter). 

Pediatric Surgery was consulted, and under ketamine/Versed sedation, incision and drainage was performed with drainage of 25 mL (milliliter) pus and hematoma. The patient was treated with an IV (intravenous) fluid bolus, vancomycin, and Zofran, and admitted late for parenteral antibiotic treatment of right shin cellulitis/abscess. Admission orders included vancomycin, follow-up cultures, and ibuprofen as needed for pain. 

The patient was feeling better, with significantly improved pain, decreased area of erythema, and no fevers. The wound packing was removed and not reapplied. He was able to move his extremity without difficulty. He was subsequently deemed stable for discharge, to complete a course of Bactrim and follow-up with his primary care practitioner the following day. 

Yes, the treatment with inpatient admission is medically necessary. 

Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient. 

This young man presented with systemic signs of infection despite outpatient therapy with one parenteral dose of clindamycin followed by three days of enteral clindamycin. The infection and inflammation spread outside the primary care practitioner's demarcation, with abscess formation and significant pain that prevented ambulation. Even though this young man was only hospitalized for a relatively short time, he failed reasonable outpatient therapy, necessitating inpatient management of his cellulitis and abscess. He could not have been safely managed at a lower level of care.