Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis, Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history significant for asthma, benign prostatic hyperplasia (BPH), hypertension, morbid obesity, paroxysmal atrial fibrillation, lymphedema, and recurrent cellulitis who presented to the hospital with complaints of fever, chills, pain, swelling, and redness in the right leg. It was reported that in the past the patient had recurrent admissions due to cellulitis and urinary tract infections. At the time of admission, the patient stated that his pannus was getting swollen and painful.
When the patient was seen by the admitting physician his temperature was 99.7 degrees Fahrenheit (F), pulse rate 86 beats per minute (bpm), blood pressure 126/64, respiratory rate 20, and oxygen saturation 95% on room air.
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The lungs were clear to auscultation bilaterally. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-distended, with positive bowel sounds. His pannus was erythematous. The right lower extremity was positive for elephantiasis. It was tender to touch. The rest of the physical exam was unremarkable.
The white blood cell count was 24.2, hemoglobin 11.7, hematocrit 36.6, platelets 360. The sodium was 137, potassium 3.9, chloride 103, bicarbonate 24, blood urea nitrogen (BUN) 10, creatinine 0.8, glucose 147. Lactic acid was 1.54. The rest of the physical exam was unremarkable.
At the time of admission, the patient was diagnosed with right lower extremity cellulitis. The patient was started on intravenous Ciprofloxacin and was recommended for elevation of the extremity and warm compresses.
In the hospital, the patient was seen by a urologist who evaluated him because of the pressure sensation over his bladder related to urination and also complaints of straining associated with urination. The urologist suggested that patient had signs of urinary tract infection and recommended continuation of treatment with antibiotics per recommendations of infectious disease service.
The infectious disease specialist evaluated the patient and diagnosed him with right lower extremity cellulitis. The infectious disease specialist mentioned that the patient was recently diagnosed and treated for a Pseudomonas urinary tract infection with bacteremia. Based on the evaluation, the patient was recommended treatment with Ciprofloxacin, Zyvox while waiting for the culture results.
The urine culture came back positive for Escherichia coli which was an extended spectrum beta-lactamase (ESBL) producer.
In the hospital, the patient was also seen by a cardiologist who recommended adjusting the medications to avoid low blood pressure. At the same time, Aldactone was added as a diuretic as well as blood pressure medication. The patient was also recommended continuing treatment with Diltiazem and beta-blocker for atrial fibrillation.
During the hospital stay, the patient's clinical condition gradually improved and he was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital stay was medically necessary.
This patient presented to the hospital with acute cellulitis and also a urinary tract infection. It is a common clinical practice to admit patients to the hospital at the acute inpatient level of care when the course of administration of intravenous antibiotics exceeds accepted limits of observation care. In this particular case, this patient required longer-term administration of intravenous antibiotics since the microorganism which caused urinary tract infection was an ESBL producer. The patient presented to the hospital with symptoms of urinary tract infection. The urine culture came back positive for Escherichia coli which was an ESBL producer.
This microorganism was resistant to many antibiotics and required treatment with intravenous antibiotics that necessitated monitoring of clinical response and potential antibiotic toxicities.
Close clinical monitoring was essential since this bacteria was resistant to many antibiotics and the clinical response to treatment was not guaranteed.
This coincides with Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 24th Edition criteria for Urinary Tract Infection. Based on the criteria, admission at the acute inpatient level of care is necessary for treatment with parenteral antibiotics beyond observation care treatment. This accurately describes the circumstances in this clinical case.
In addition to the urinary tract infection, the patient also required antibiotics for the treatment of concomitant cellulitis. The complexity of the patient's condition and intensity of care provided justified admission at the acute inpatient level of care, as was outlined in the previous sections of this report.