Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Bilateral foot swelling, redness and fever for three days.
Treatment:  Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is a young adult female with history of delivery one month prior with pre-eclampsia but no residual noted abnormalities, who presented to the hospital with bilateral foot swelling, redness and fever for three days. She had been wearing tighter than usual shoes and had excoriations / blisters of her feet that led to subsequently redness and warmth with pain. The patient had a fever of 102 Fahrenheit and was initially tachycardic to 127 beats per minute, but with mean arterial pressure over 65 milligrams of mercury (mmHg). She did not have any major medical history. The patient's feet did not demonstrate any findings of necrosis, deep soft tissue infection, new onset violaceous discoloration, neuro-vascular compromise, deep wound, foul odor, purulence or streaking up the extremity. The patient had a normal mental status. System examination and review of systems was normal. The patient's white blood cell (WBC) count was normal and so were platelet and hemoglobin counts. The patient had normal kidney and liver function tests with normal anion gap, bicarbonate, and lack of lactic acidosis. The patient also had an x-ray of the feet performed showing no bone abnormality or wound or gas. No crepitus was palpable at the local site. There was no pain out of proportion to the physical findings. The patient was given intravenous antibiotics, Infectious Diseases (ID) was consulted, intravenous fluids were given, intravenous acetaminophen was administered, and Podiatry consultation was sought. The patient improved rapidly and was discharged on the second day on oral therapy.

The proposed treatment was not medically necessary.

Inpatient hospitalization is required when a patient's clinical condition, assessed based on symptoms, signs, lab data and imaging information, comorbid conditions and symptom severity, indicate a high level of illness severity and a high risk for adverse events if patient is not admitted to the hospital. In this patient's case, there were no comorbid conditions of importance. She was not diabetic, did not have a history of recurrent infections or immune compromise, was breast feeding but not pregnant and did not have any residual impact of prior pre-eclampsia. The patient had an elevated temperature on presentation and tachycardia with a mean arterial blood pressure more than 65 millimeters of mercury. She also had a normal review of systems and general systemic examination. There was redness and excoriation of bilateral feet with prior blisters but no active blisters, crepitus, purulence, streaking, violaceous discoloration, gangrene or neuro-vascular compromise. She did not have an ulcer, or diabetes mellitus. She did not have intractable pain or vomiting. She was able to take medication orally. The patient's white cell count, kidney function tests, electrolytes, bicarbonate, anion gap and liver function tests were all normal. No imaging abnormality was noted other than soft tissue swelling. This is clearly a very low risk condition for adverse consequences. Not every patient who has fever with cellulitis needs hospitalization. This patient had no comorbid conditions, no intractable symptoms, no local findings of necrotizing infection, no failure of outpatient therapy, no signs of systemic organ dysfunction or any other issue that would preclude observation then discharge on appropriate oral therapy. She also did not have any odd epidemiological exposure such as sea water or brackish water or animal bite etc. With a low severity of illness and low risk of progression of illness with oral and observation therapy, inpatient level of care was not medically necessary.