Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right Lower Extremity Cellulitis.
Treatment:  Inpatient Hospital.

The insurer denied Inpatient Hospital.  The denial is upheld.

The patient is an adult male with a past medical history significant for diabetes mellitus, alcohol abuse, attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, and opioid abuse. The patient presented with complaints of right lower extremity swelling and redness. The patient gave history that the symptoms started about a week ago, and he noticed his leg became discolored and swollen. The patient has a history of recurrent cellulitis of the lower extremity in the past. The patient denied fever or chills, but he reported history of nausea and vomiting. The patient has been on minocycline for prophylaxis of the recurrent cellulitis, and he is compliant with that. The patient's vital signs on presentation were blood pressure 112/73, heart rate 76, respiratory rate 18, and temperature 97.8. Labs showed erythrocyte sedimentation rate (ESR) 28, procalcitonin 3.9, and C-reactive protein 44. The patient was treated with intravenous fluids and intravenous Unasyn and was admitted to inpatient hospital stay for continued treatment. Ultrasound was negative for deep vein thrombosis (DVT). The patient was evaluated by Infectious Disease consult and also by Vascular Surgery consult. Computed tomography (CT) scan was planned, and this was obtained, but did not show any collection or abscess. The patient was continued on intravenous Unasyn with continued improvement. The patient was discharged on oral antibiotics.

The requested health service was not medically necessary.

Inpatient medical admission is not medically appropriate for the above duration. The patient presented with right lower extremity cellulitis and was treated with intravenous antibiotics. However, the patient was afebrile on admission and had stable vital signs. Clinical evaluation and review of lab results do not show any findings to indicate the patient had sepsis / septic shock that may need inpatient admission for treatment. Additionally, the patient was not immunocompromised, the area of involvement in this case was not located over a prosthesis or implanted device, and the patient did not have involvement of the eye (orbit). In view of this, inpatient medical admission was not needed for the above duration. For the requested dates of service, 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 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 workup in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for workup or change in management plan in an inpatient setting. The patient's diagnosis had been established clinically and based on the results of the investigations. Care rendered during this time was of low intensity, routine nursing and physician monitoring. 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 requested dates. In view of these findings, therefore, the ongoing inpatient level of care was not medically necessary.