Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Cellulitis.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This is a case of a male admitted for a diagnosis of left lower extremity cellulitis. The patient presented with a chief complaint of left lower extremity cellulitis. In the emergency department he was found to have a white blood cell count of 9.2 and was treated with Merren 1 gram. Vital signs demonstrated a temperature of 98F., a pulse of 77 beats per minute (bpm), a respiratory rate of 18/minute, a blood pressure of 102/69 millimeters of mercury (mmHg) and an oxygen saturation of 98%. Physical exam showed the patient to be in no acute distress or altered mental status. There was 2+ lower extremity edema. His blood urea nitrogen (BUN) was 20.9 and chemistries were otherwise normal. It was noted that there was no evidence of sepsis, and he had no fever. An ultrasound was obtained to evaluate for deep vein thrombosis (DVT), and it was negative. Infectious disease evaluated the patient, and he was treated with Linezolid, given a history of methicillin-resistant staphylococcus aureus (MRSA) and an antibiotic allergy profile. A vascular surgery consult was requested who recommended no surgical intervention. He was given Nystatin cream for a fungal infection of the bilateral toes and was discharged.
At issue is the medical necessity for the inpatient stay.

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

No, the medical necessity of the admission has not been established.
According to Up-to-date, 2021:
"Oral versus parenteral therapy - Patients with mild infection may be treated with oral antibiotics. Treatment with parenteral antibiotics is warranted in the following circumstances:
-Systemic signs of toxicity (e.g., fever >100.5F/38C, hypotension, or sustained tachycardia)
-Rapid progression of erythema
-Progression of clinical findings after 48 hours of oral antibiotic therapy
-Inability to tolerate oral therapy
-Proximity of the lesion to an indwelling medical device (e.g., prosthetic joint or vascular graft).

The decision to initiate parenteral therapy should be based on individual clinical circumstances such as severity of clinical presentation and patient comorbidities. As an example, the presence of an immunocompromising condition (such as neutropenia, recent organ transplant, advanced HIV (human immunodeficiency virus) infection, B cell or T cell deficiency, or use of immunosuppressive agents) should lower the threshold for parenteral therapy."
According to the documentation submitted the patient did not have fever, hypotension, tachycardia, rapid progression of erythema, worsening of findings after 48 hours, inability to tolerate oral therapy or proximity of lesion to an indwelling medical device. There was no history of neutropenia, organ transplant, HIV, B cell or T cell deficiency or use of immunosuppressive medication.
Although the patient required services in the hospital setting, the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered at an alternate level of care. Therefore, the medical necessity of the admission has not been established.