Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient hospital admission
The insurer denied inpatient hospital admission.
The determination is upheld. 

The patient is a male with bipolar disorder, depression, post-traumatic stress disorder (PTSD), polysubstance abuse, and homeless, who presented to the emergency department (ED) with complaints of (c/o) left (L) ankle pain times (x) 1 week after an accidental needle puncture. He was seen in the ED previously for needlestick injury and discharged on oral Bactrim and human immunodeficiency virus (HIV) post-exposure prophylaxis. An x-ray at that time was negative for fracture. On return to the ED, the patient reported he was unable to fill the original prescriptions.
The patient had c/o pain, warmth, swelling, pain at a 10/10 and was unable to ambulate due to pain. Vital signs (VS) in the ED were a temperature at 99 degrees Fahrenheit, blood pressure was 112/85, heart rate was 96, respiratory rate (RR) was 18, and room air (RA) pulse oxygen saturation was 98% (percent). The exam noted L (left) ankle with diffuse swelling and edema, erythema, warmth, and tender to palpation. Pulse, motor, and sensation all were grossly intact.
The x-ray of ankle again showed no fracture, soft tissue swelling over medial malleolus, no gas, no acute abnormalities.
Labs on admission were a white blood cell count (WBC) at 11.6, hemoglobin and hematocrit (H/H) was 12.2/35.4, creatinine was 0.73, normal liver functions, creatine phosphokinase (CPK) was 198, Lactate was 1.6, and negative Troponin. The urine drug screening (UDS) was positive for cocaine. A urinalysis (UA) showed trace ketones, trace protein. Erythrocyte sedimentation rate (ESR) was 25, and C-reactive protein (CRP) was 4.7. Hepatitis C virus (HCV) was negative.
He was admitted for cellulitis of the L ankle. He was started on empiric Zosyn, then Unsayn, and Vancomycin, morphine for pain, and social work (SW) was consulted for discharge planning to a shelter.
HIV was negative. The progress note reported L ankle with mild erythema and trace edema. He remained afebrile and hemodynamically stable throughout. His pain was managed with ketorolac and oxycodone. 
He was discharged on oral Bactrim for 7 days, and to complete 28 days of HIV post-exposure prophylaxis (PEP) with Biktarvy, with outpatient follow-up arranged.
At issue is the medical necessity of inpatient hospital admission.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.
This patient had been seen in the ED previously for L ankle pain after a needlestick injury. X-ray of the ankle at that time showed no acute abnormalities. He was discharged with prescriptions for oral Bactrim, and for HIV post-exposure antiretroviral prophylaxis. He did not/was not able to fill these and returned to the ED with L ankle pain and signs of cellulitis. He was afebrile and with stable vital signs (VS), was alert & oriented, x-ray showed some soft tissue swelling, and labs showed a mild leukocytosis. UDS was positive for cocaine.
He was treated for ankle cellulitis with empiric intravenous (IV) antibiotics and monitored for signs of ethyl alcohol (ETOH) withdrawal. He remained afebrile and hemodynamically stable. He did not have an altered mental status, he did not have uncontrolled pain, he had no signs/symptoms consistent with (c/w) sepsis, he did not have respiratory distress or need for supplemental oxygen, he did not have cardiac arrhythmia, and he did not require continuous monitoring. He did not have a necrotizing skin and soft tissue infection (SSTI), infection overlying an implanted device, or periorbital cellulitis. He did not have an abscess collection or need for invasive procedure. He did not fail outpatient therapy as he had never filled the prescriptions provided. This patient had ankle cellulitis, and he responded to empiric antibiotics. The patient was not appropriate for an inpatient level of care.