Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is upheld. 

The patient is a male. He was admitted for an acute hospital stay for failed outpatient treatment of an elbow infection. The patient has a past medical history of eczema, and cellulitis that was treated with Augmentin. He was started on Cephalexin 250 milligrams (mg) twice a day for a cellulitis after a bug bite to the right elbow prior to this admission, as well as topical Bactroban. After 3 doses of the antibiotic, he had a temperature of 103 at home. An ambulance was called, and he was taken to the emergency department (ED). In the ED, he was noted to be febrile to 103.1, heart rate of 151, respiratory rate of 28 , and labs were done secondary to a sepsis screen. His labs showed a C-reactive protein (CRP) of 2.14, neutrophils of 73.2% and otherwise labs were reassuring. An x-ray was done of the elbow and showed soft tissue swelling. In the ED he was given an intravenous (IV) bolus and was given one dose of Vancomycin in the ED, Tylenol, and ibuprofen.
He was admitted. The patient's fever had improved to 97.7 and he remained afebrile through the hospital course. Infectious disease was consulted and gave Cefazolin 280mg every 8 hours. Blood culture showed no growth. Improvement of cellulitis was noted, no fevers, and the patient was sent home to continue Cephalexin three times a day (versus twice a day) for the next 5 days.
At issue is the medical necessity of the Inpatient Admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient.
Clinical Infectious Diseases [1]  recommend that most typical cases of cellulitis without systemic signs of infection can be treated with oral medication as an outpatient. It appears that this was attempted for this patient. They do consider patients with cellulitis as "moderate infection" if they have typical cellulitis/erysipelas with systemic signs of infection or have failed outpatient treatment. They define systemic signs of infection such as temperature greater than (>) 38 degrees () Celsius (C), tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (less than [<]12 000 or < 400 cells/microliter [L]), or immunocompromised patients, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction. In these patients they recommend intravenous antibiotics.
This patient with concerning symptoms of failed outpatient treatment coupled with concerning systemic signs of infection and the determination of intravenous antibiotics was appropriate, however an inpatient level of care was not medically necessary. After receiving one dose of intravenous antibiotics this patient improved in physical exam findings, as well as vital signs. He remained afebrile throughout his hospital course, with normal vital signs.
Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary.