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 with a past medical history of hypertension and schizoaffective disorder. He was brought to the emergency department for urgent evaluation of diffuse pain and unusual behavior. EMS (emergency medical services) reported that a bystander saw him on the ground, sobbing and moaning in pain, prompting them to call 911. He was shivering and complaining of pain all over his body, his left arm, and his right heel, appearing very restless in bed. He reported being attacked with a knife by a group of people 5 days prior, and sustaining a laceration to his left forearm, and also reported being attacked with a machete to his right lower extremity one month prior. He also reported smoking crack that day in an attempt to alleviate the pain. 

The patient's vital signs showed temperature 99.2 degrees Fahrenheit, pulse rate 98 beats per minute, and blood pressure of 105/65. On examination, he had an area of swelling, warmth, erythema, and tenderness to his left forearm, approximately 6 centimeters and curvilinear, as well as an old lesion on the right lower extremity in the area of the Achilles tendon. He was disoriented, only oriented to himself, unable to state the date, month, year, president, or the type of location he was in, being of the belief that he was located in a dental office at the time of the examination. 

In the emergency department, the patient received IV (intravenous) vancomycin and Unasyn, and trauma surgery was consulted. Labs were done, revealing lactic acid at 2.10 mmol/L (millimole per liter). There was initial concern that he may be intoxicated causing his confusion, and so he was observed until clinical sobriety. Five hours later, it was noted that his alcohol level was negative. 

The patient was admitted to an inpatient level of care for further management of cellulitis due to stab wound. The patient was treated with IV (intravenous) antibiotics and hydration. Blood cultures were obtained. The patient was also evaluated by psychiatry and diagnosed with substance induced psychosis, as well as malingering and factitious disorder. The patient was stabilized and discharged. 

No, the Inpatient admission was not medically necessary. 

Inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk as based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition. 

In this case for the duration of the inpatient admission, the patient was afebrile and had stable vital signs. The patient required antibiotics for cellulitis, but he had not failed oral antibiotics before presentation to the ED (emergency department). The patient could benefit from antibiotics, however he did not absolutely need IV (intravenous) antibiotics. The clinical presentation did not necessitate initiation of IV (intravenous) antibiotics. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any exam findings that would necessitate further work up 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 continued inpatient stay in the hospital. During the above duration, the patient's diagnosis had been established clinically and based on the results of the investigations. The patient was hemodynamically stable and afebrile. For the above duration, the patient had stable vital signs and 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. Although the patient had pain, it was not intractable, and not noted to be amenable to appropriate oral treatment. 

Care rendered during this time was of low intensity, routine nursing and physician monitoring. No systemic findings such as high fever, 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 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. In view of these findings and generally in accordance with MCG (Milliman care guidelines) guidelines therefore, the ongoing inpatient level of care for the above duration was not medically necessary. 

During the above duration, the patient's main clinical need was to ensure that the patient was responding to the treatment and this could have been safely and effectively managed in an observation level of care. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.