Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders 
Treatment: Inpatient Hospital 
Denied: Inpatient Stay 
Denial: UPHELD in whole 

The patient is a female with a past medical history significant for gastroesophageal reflux disease (GERD), hypothyroidism, obesity, and osteopenia who presented to the emergency department with complaints of worsening left leg redness, swelling, pain, fever, and chills. 

Reportedly, the patient went to see her primary care physician several days before the day of the presentation because of the same symptoms and was started on Augmentin. 
Despite treatment with oral antibiotics, the redness and tenderness in her leg continued to worsen. At the same time, the patient denied any fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, or changes in bowel movements. On the physical exam, the patient was afebrile, heart rate was 80 beats per minute, respiratory rate 18, blood pressure 145/90, oxygen saturation 99% room air. 

On the physical exam, the patient was in no acute distress, she had diffuse erythema that was hot to touch on the interior surface of the ankle and shin with tenderness along the medial aspect of the shin. There was some edema noted. The cardiovascular exam was unremarkable. Lungs were clear to auscultation. The abdominal exam was within normal limits. The rest of the physical exam was unremarkable. Laboratory evaluation revealed that sodium was 141, potassium 3.6, chloride 103, bicarbonate 31, blood urea nitrogen (BUN) 21, creatinine 0.5, glucose 90. White blood cell count was 7.55, hemoglobin 13.0, hematocrit 41.7, and platelets 222. 

In the hospital, the patient underwent left lower extremity venous duplex study that demonstrated no evidence of left lower extremity deep venous thrombosis. The patient was admitted to the hospital with left lower extremity cellulitis that failed outpatient treatment. The patient was started on intravenous antibiotics (Ancef). As a result of the treatment, the redness and swelling in the left lower extremity improved. The patient was discharged home with a prescription for an oral antibiotic (Keflex). 

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

The inpatient stay was not medically necessary. In this clinical case, the patient received treatment with Augmentin, which was not one of the anti-staphylococcal penicillins, and the patient did not respond adequately to the treatment. According to the Merck Manual Professional Version online, treatment with Augmentin is recommended in cases of mild cellulitis caused by mammalian bites. Taking into consideration these facts, it would not be fair to say that the patient failed outpatient treatment, because the antibiotic coverage was not adequate. 

In addition to that, at the time of the presentation, this patient was afebrile, hemodynamically stable, had no signs of sepsis, and had normal white blood cell count, and she did not have high-risk features or comorbidities. Therefore, this patient could have been treated with appropriate IV antibiotics at a lower level of care status. An inpatient admission was not medically necessary. 

This determination coincides with the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 23rd edition criteria for Cellulitis. Based on the criteria, patients require admission at the acute inpatient level of care in cases when they fail an outpatient treatment defined as progression or no improvement after an adequate trial of appropriate antibiotics. In addition to that, the patient did not meet the criteria since she had no limb-threatening infection or high-risk comorbid conditions such as uncontrolled diabetes mellitus, liver cirrhosis, symptomatic heart failure, bacteremia, altered mental status, hemodynamic instability, or some other conditions that were not applicable in this clinical case. 

The review of the medical records demonstrated that the severity of the patient's condition did not rise to the acute inpatient level of care.