Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis of the Right Lower Extremity. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a male with a past medical history of alcohol and polysubstance abuse who presented to the emergency department with a worsening right leg wound. The patient reported sustaining a laceration to the right calf above the ankle on the posteromedial side after kicking a glass window. The initial management occurred at another facility, where the wound was sutured, and a single dose of intravenous (IV) Cefazolin was administered. However, the patient did not adhere to the prescribed antibiotics. The patient returned to the emergency department (ED) due to one suture being dislodged, and wound care was provided. Subsequently, the patient sought care at another ED, reporting purulent fluid drainage from the wound. The sutures were removed, and antibiotics were prescribed but not taken by the patient.
Upon admission, the patient complained of persistent pain at the wound site and noted clear to yellow fluid discharge. The physical examination revealed the patient to be afebrile, with vital signs showing a pulse rate of 60 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 118/71 millimeters of mercury (mmHg), and his oxygen saturation was 99 percent (%) on room air. The cardiovascular assessment revealed a normal heart rate and regular rhythm with normal heart sounds. The pulmonary evaluation indicated normal effort and breath sounds. The abdominal examination revealed a soft abdomen without tenderness or guarding. In the musculoskeletal assessment, a lacerated wound on the right lower leg above the ankle on the posteromedial side was observed, accompanied by mild swelling around the wound site and on the right foot, which elicited tenderness upon palpation. The skin appeared warm, and the neurological examination did not reveal any focal deficits. The patient exhibited an alert mental status. 

The laboratory evaluation revealed that white blood cell count was 5.9, hemoglobin 11.2, hematocrit 32.5, and platelets were 246. His sodium was 139, potassium 4.1, chloride 105, bicarbonate 28, blood urea nitrogen (BUN) 15, creatinine 0.9, and liver function tests were unremarkable. The patient was admitted to the hospital with mild cellulitis of the right lower extremity, which was attributed to traumatic laceration and medical noncompliance. The patient received treatment with intravenous Cefazolin, also intravenous pain medications, and nausea medications. The secondary diagnosis was tobacco use disorder, cannabis use disorder, and cocaine use disorder. As a result of the treatment provided in the hospital, the patient's clinical condition significantly improved, and the patient was transitioned to outpatient care. 

In general, admission at the acute inpatient level of care is indicated for patients with cellulitis and soft tissue infection that failed outpatient therapy, in cases of limb-threatening infection, or rapid progression of the infection that necessitated high-intensity monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus or liver cirrhosis. 

Admission at the acute inpatient level of care is also indicated for patients with cellulitis and bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection, or oral cellulitis, or when patients need a surgical procedure not amenable to outpatient or emergency department care. 

Admission for a short period at an alternate level of care was reasonable to ensure a response to antibiotics and in order to decide about antibiotic treatment after discharge. 

The health plan's determination of medical necessity is upheld in whole.