Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bacterial Skin Infection
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female with history of opioid intravenous use, bipolar disorder, history of sickle cell disease complicated by (c/b) bilateral hip necrosis status post right (R) total hip replacement, deep vein thromboses (DVTs), schizophrenia, vaso-occlusive disease and suicide attempt in the past. The patient presented to emergency department with both arms in pain and with swelling that started 2 days prior, and lower back and knee pain that started 1 day prior. The pain was eight out of ten (8/10), worse in the left arm, located in the left shoulder, both wrists, both knees and lower back. She reported being at another hospital the previous day and received oral (PO) analgesics when assessed with pain crisis episode; however, she refused admission there. Previously she visited the other hospital emergency department and reportedly developed left arm swelling after an intravenous line. The patient had previously been evaluated in the emergency room and left against medical advice but reported that she was taking Bactrim for the past 2 days and the pain and swelling had persisted. The patient was febrile on presentation - temperature was 101.3 Fahrenheit (F) and on evaluation, the left arm was edematous, erythematous, and tender to palpation. Evaluation was concerning of possible limb ischemia as swelling worsened compared to the prior evaluation. Evaluation also showed abdominal tenderness (diffuse tenderness). The patient was started on intravenous fluid and intravenous antibiotics including vancomycin and pain medications and was admitted to inpatient stay for further management. The patient signed out against medical advice on the following day before treatment could be completed.

The requested health service was medically necessary.

Inpatient admission was appropriate for the requested dates. This patient's presentation was suspicious for sepsis secondary to left arm cellulitis; rule out deep vein thrombosis and there was concern to rule out compartment syndrome as a possible 
complication of intravenous drug use. The patient was febrile on presentation at 101.3 Fahrenheit (F) and tachycardic with a pulse rate of 100. Labs showed leukocytosis with a white blood cell (WBC) count of 26.6. The patient was evaluated by Infectious Disease consult who advised continued treatment with vancomycin. Ultrasound showed bilateral cobblestoning consistent with cellulitis. X-rays of the left hand showed soft tissue swelling in the hand with some amount of air in the volar aspect of hand. Inpatient admission was appropriate in view of the above presentation that showed the patient was febrile on presentation with history of sickle cell disease, white blood cell count of 26 thousand, who had been on Bactrim without improvement, and the upper extremity evaluation concerning for compartment syndrome that required vascular surgery evaluation. Inpatient admission was appropriate to ensure that patient received the appropriate treatment and to ensure that continued improvement was noted to the treatment being given including intravenous vancomycin. The concern for compartment syndrome was real and required appropriate follow up to ensure that the patient was responding well to prevent such complication. Inpatient admission was medically appropriate to ensure that above plan was properly implemented to ensure appropriate improvement without complications. Such plan of treatment and follow up would not be able to be completed at a lower level of care and inpatient admission was appropriate for this patient.