Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cellulitis.
Treatment:  Inpatient Hospital Admission.

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

The patient is an adult female with past medical history significant for asthma who presented to the emergency room, as she was concerned that the wound on her right leg was infected, as she had noticed purulent yellow and white discharge from the wound for one day. The patient had noticed purulent discharge after taking a shower the day before presentation to the emergency room. 

The patient was previously evaluated in the emergency room when she presented to the emergency room after falling out of a moving car and sustaining a large wound to the right leg. The patient was treated with one dose of intravenous antibiotics in the emergency room and was sent home on oral antibiotic Keflex. The patient reported taking the Keflex. 

Evaluation in the emergency room showed the following vital signs: temperature (T) 97.9, blood pressure 117/74, pulse 78, respirations 18, and pulse oximetry 100%. Evaluation in the emergency room showed that patient had an abrasion on the right lower extremity from the inferior aspect of knee to the mid lower leg, wound with purulent drainage and surrounding erythema and warmth. The patient was treated with intravenous vancomycin in the emergency room; however, she developed itching, so the antibiotic was switched to intravenous clindamycin. Results of the labs showed the following: chemistry - no major abnormalities noted; white blood cell (WBC) count 9.9, platelets 310, hemoglobin 15.2, international normalized ratio (INR) 1.0, prothrombin time (PT) 13.2, and C-reactive protein (CRP) 14.45. Computed tomography (CT) scan of right lower extremity showed findings compatible with the clinical evaluation of cellulitis. No definite fluid collection or abscess was identified. Consultation was requested from Infectious Disease and Surgery and the patient was admitted to inpatient hospital care for leg cellulitis. 

During the patient's hospital stay, the patient was evaluated by Infectious Disease and was recommended to change antibiotics from Clindamycin to Unasyn; the patient continued treatment with intravenous Unasyn. Surgery consult did not recommend any drainage or surgery. The patient was continued on intravenous Unasyn and continued to improve. The patient was discharged home on Day #4.

Medical necessity for inpatient hospital admission is not established.

The patient was discharged home with oral antibiotics, Keflex, on prior evaluation in the emergency room. However, the new concern of right leg wound was noted to have discharge for one day before presentation to the emergency room. The patient did not have complaints of fever before coming to the emergency room. Evaluation in the emergency room also showed that the patient had stable vitals and was afebrile. The patient did not have tachycardia or low blood pressure to indicate possible systemic effects / sepsis due to the infection. Lab results in the emergency room also showed normal white blood cell (WBC), normal international normalized ratio (INR), platelets and chemistry results without any major abnormalities. Computed tomography (CT) scan did not show any drainable collection that would necessitate admission to hospital for drainage. The patient presented without fever. The evaluation did not show signs concerning for systemic infection or sepsis and there was no immediate need identified that would necessitate admission to the hospital for further work up or treatment. The patient could have been safely and effectively managed at a lower level of care setting without admission to the hospital.