Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders - Cellulitis.
Treatment: Inpatient Admission.
The insurer denied Inpatient Admission.
The denial is overturned.

The patient is a female with a history of polysubstance abuse, intravenous (IV) drug abuse, untreated hepatitis C, multiple hospitalizations recently for recurrent cellulitis of the lower extremities, requiring IV antibiotics (abx) and then leaving against medical advice (AMA). She presented with increasing pain in the lower extremity with associated open wound, multiple ulcers, purulence. She had a large wound close to the inner thigh. She was tachycardiac but otherwise afebrile.
Her labs showed leukocytosis and a computed tomography (CT) scan of the lower extremity showed findings consistent with cellulitis but no abscess. At attempt was made to place an IV site, but she had very poor access. Femoral line was placed with plan to place a peripherally inserted central catheter (PICC) line. She was started on Vancomycin and Zosyn. She was seen by general surgery, and they recommended debridement that was attempted but she deferred it due to significant pain. She was placed in Clinical Institute Withdrawal Assessment (CIWA) due to her history of heroine abuse; opiates abuse and benzodiazepine abuse. She was started on IV Toradol and Oxycodone. Methadone was also started. Social worker was involved. Blood cultures were obtained. However, the patient left against medical advice without completing the antibiotics.
At issue is the medical necessity of the Inpatient Admission.

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

Yes, the requested health service/treatment of Inpatient Admission was medically necessary for this patient.
The patient had a high risk recurrent/persistent infection on the lower extremity with purulence and she also had a high risk for methicillin-resistant staphylococcus aureus (MRSA) and multidrug resistant bacterial infection. Moreover, the pain management was very challenging in this patient. Based on the review of the records, medical literature and current best practices, the health plan did not act reasonably in its determination of the medical necessity. She has a history of polysubstance abuse, IV drug abuse, untreated hepatitis C, multiple hospitalizations recently for recurrent cellulitis of the lower extremities, requiring IV abx and then leaving AMA. The patient met the criteria for inpatient admission due to concern for multidrug resistance and MRSA infection as indicated by frequent infections, IV drug abuse, immunocompromised status (from IV drug abuse and the active hepatitis C). [1,2] The patient also needed surgical debridement and her pain management was an issue due to her history of drug abuse and very low pain tolerance. In addition, per the Milliman Care Guidelines (MCG) health inpatient & Surgical care 26th Edition Cellulitis ORG: M-70 (ISC), the inpatient admission is recommended when surgical procedure including debridement is indicated (as in this patient) as well as requiring inpatient pain management (the patient's history of opiate abuse and IV drug abuse was making the pain management very challenging). [3]
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary.