Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection (on foot).
Treatment: Inpatient admission.

The insurer denied Inpatient admission.  The denial is upheld.

The patient is an adult male with a medical history significant for chronic obstructive pulmonary disease (COPD), alcohol dependence, hypertension, diabetes, and anemia. The patient presented to the emergency room with right foot pain and swelling for two days. The patient denied any history of injury, fall, or trauma to the right foot. The patient reported that he noticed that the foot was diffusely swollen, and he had inability to bear weight. In the emergency room, the patient's vital signs were as follows: blood pressure 134 over 76 (134/76), pulse 82, temperature 97.9 Fahrenheit, and pulse oximetry 98% (percent). The patient's labs showed the following values: calcium 7.7, white blood cell 13.2, hemoglobin/hematocrit 12.3/35.2, erythrocyte sedimentation rate (ESR) 20, and C-reactive protein (CRP) 26.4. X-ray of the right foot showed diffuse tissue swelling of the foot and mild plantar calcaneal spurring. Ultrasound Doppler showed no evidence of deep vein thrombosis (DVT). The patient was started on intravenous antibiotic Ancef and also given pain relief with Toradol and Oxycodone. The patient continued to improve on treatment over the next two days. The plan was to obtain magnetic resonance imaging (MRI) of the foot. The magnetic resonance imaging could not be completed immediately, and the patient signed out against medical advice on day number 4 (#4), and he left the hospital.

The inpatient admission was not medically necessary.

Inpatient medical admission was not needed for the above duration. The patient presented with left foot / leg cellulitis and needed treatment with antibiotics. The patient had no history of injury prior to presentation, and he did not have an open wound on presentation. This patient had not failed outpatient antibiotics before presentation to emergency room. The patient was afebrile on presentation and had stable vital signs without any change in mental status. Additionally, the patient was not immunocompromised, the area of involvement in this case was not located over a prosthesis or implanted device, and the patient did not have involvement of the eye (orbit). In view of this, inpatient medical admission was not needed.

The patient's diagnosis had been established clinically and 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. The patient's temperature and other vital signs were not representative of sepsis during this time. General and systemic examination was normal or at baseline. The patient was able to eat food, drink fluids and take oral medications. Although patient had pain, it was not intractable, and noted to be amenable to appropriate oral treatment.

The care that was rendered during this time was of low intensity, routine nursing, and physician monitoring. No systemic findings such as high fever, shock, renal or liver failure, or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. The patient was not in acute distress. In view of these facts of the patient's clinical status, ongoing risk of deterioration was low, since diagnosis had been established and the patient was responding appropriately to the treatment. Since the intensity of interventions was routine, 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.