Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg cellulitis. 
Treatment: Inpatient admission. 

The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is an adult female who presented to the emergency room for complaint of right leg pain and swelling. The patient reported that she felt sore on the right calf a few days prior to admission. She developed worsening pain, swelling and came to the emergency department. She reported slightly bumping the leg on the bed a few days ago. She denied any other trauma. She denied fever or chills. She denied chest pain or shortness of breath. The patient's past medical history includes uterine fibroids and history of dilatation and curettage. The patient's evaluation in the emergency room showed edema and tenderness of the right calf with minimal erythema. No ecchymosis or open wound was noted. The patient was afebrile on presentation and vitals were temperature - 97.9, pulse - 94, blood pressure 179/102, respirations - 18, and pulse oximetry - 99 percent (blood pressure improved to 138/78 over the next few 
hours). Labs showed a blood urea nitrogen (BUN) of 7, potassium of 3.8, white blood cell (WBC) count of 7.8, and platelets of 296. Lower extremity venous duplex revealed no evidence of deep venous thrombosis of the right lower extremity and revealed right popliteal fossa through calf mixed echogenicity complex fluid collection which is nonspecific and likely represents a hematoma. The patient was started on intravenous antibiotics, vancomycin, and surgical consult was requested. The patient was evaluated by surgery and advised there was no need for immediate drainage of the possible collection in the right calf; and advised continuing antibiotics and 
follow-up. The patient was admitted for treatment of cellulitis and continued on antibiotics. The patient improved and was discharged. 

The proposed treatment was not medically necessary. 

Inpatient admission for the above duration was not medically necessary. The patient presented with cellulitis of the right calf; however, the patient was otherwise clinically stable on presentation. The patient was afebrile and had stable vital signs and was awake and alert without any changes in mentation. Lab values did not show presence of severe infection / concern for sepsis on presentation. Deep vein thrombosis study showed possible hematoma and the surgical evaluation clearly advised no immediate need for drainage. The patient needed treatment with antibiotics for the cellulitis, however inpatient admission was not needed as there was no concern for sepsis / septic shock and no immediate treatments / procedures were needed that would require inpatient admission. The patient's diagnosis had been established clinically and was based on the results of the investigations. The patient was hemodynamically stable and afebrile. The patient had stable vital signs and routine labs remained at baseline. General and systemic examination was normal or at baseline. The patient was able to eat food, drink fluids and take oral medications. Although the patient had pain, it was not intractable, and not noted to not be amenable to appropriate oral treatment. Care rendered during this time was of low intensity, routine nursing and physician monitoring. 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.