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 female with medical history significant for lupus, edema, fibromyalgia, rheumatoid arthritis (RA) and cervical cancer who presented to the emergency department (ED) for evaluation of severe pain to the left foot. The patient reported that she woke up in the morning and when she got up to walk she felt severe pain in the left foot. She reported having chronic bilateral lower extremity edema. She reported having a fever (102 Fahrenheit (F)) at home, and it improved after she took motrin. The patient also reported headache. 

Evaluation in the emergency room (ER) showed temperature (T) - 36.7 celsius (C) , pulse (P) - 91, respiratory rate (R) - 18, pulse oximetry - 97%, and blood pressure (BP) 172/93.  In the emergency department, the patient was noted to have diffuse erythema and warmth to the left leg and bilateral lower extremity edema. White blood cell (WBC) count was 15.3, remainder of the labs were non actionable. 

The patient was admitted for cellulitis of left lower extremity and treated with intravenous (IV) antibiotics (Kefzol) and pain medications. The patient refused to undergo ultrasound doppler. The patient was started on amlodipine for elevated blood pressure (BP).  The patient improved and she was discharged in three days.

No, the proposed treatment (Inpatient Hospital Admission) was not medically necessary.

Based on the available information, the patient could be safely and effectively managed without inpatient hospital admission.

The proposed treatment (Inpatient Hospital Admission) was not medically necessary. Based on the available information, the patient could be safely and effectively managed without inpatient hospital admission.

During this admission, the patient presented with complaints of pain to the left foot and subjective fever. The patient denied cough, cold, dizziness, confusion,  nausea or vomiting and the patient was able to tolerate oral intake upon presentation and during hospital stay. Evaluation in the emergency room (ER) showed (T) - 36.7 celsius (C), pulse (P) - 91, respiratory rate (R) - 18, pulse oximetry - 97%, and blood pressure (BP) 172/93. Vitals were stable, except for elevated blood pressure (BP) and the patient was afebrile. Admission labs showed white blood cells (WBC) 15.3; unremarkable chemistry and nonactionable other labs. The patient had not been treated with and failed antibiotics in outpatient to necessitate inpatient stay for treatment. 


Continued 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. 

For the duration, the patient was afebrile and had stable vital signs. Patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. 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 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. The patient's temperature and other vital signs were not representative of sepsis during this time.  The patient was able to eat food, drink fluids and take oral medications. Although 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.   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 was not in acute distress and in view of these facts of the patient's  clinical status, ongoing risk of deterioration was low since diagnosis had been established.  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  therefore, the ongoing inpatient level of care for the above duration was not medically necessary.