Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin infection.
Treatment: Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult male with past medical history significant for diabetes and hypertension. The patient presented to the emergency room with complaints of worsening left elbow pain, swelling and redness with a break in the skin. The patient reported that he had sustained a traumatic injury to the elbow that he sustained from a fall. The patient also reported using an antibiotic ointment at home, before presentation to the emergency room. The patient's physical examination in the emergency room (ER) showed that the patient had erythema, tenderness of the involved area, and he had decreased range of motion of the elbow. The swelling and tenderness also extended posteriorly along the distal triceps region and inferomedially along the medial forearm and possible fluctuance. The patient's vitals on presentation showed a blood pressure (BP) of 147/90 and pulse of 101. Labs were notable for white blood cells (WBCs) 14 thousand (K), erythrocyte sedimentation rate (ESR) 28, C-reactive protein (CRP) 29, glucose 244, and sodium 132. Left elbow x-ray revealed soft tissue swelling dorsal to the proximal ulna, questionable chip of the proximal ulna. The patient was admitted for treatment of cellulitis and septic olecranon bursitis. Orthopedic evaluation recommended possible drainage and treatment with intravenous antibiotics. In the emergency room, the patient was started on treatment with intravenous fluids, intravenous cefazolin and vancomycin. A test for respiratory syncytial virus (RSV) was positive. During the inpatient stay, the patient was treated with intravenous Unasyn and continued on intravenous fluid. Potassium repletion was done for hyperkalemia. On day #2, the patient underwent aspiration of the elbow and was continued on intravenous antibiotics. On day #4, culture revealed staph aureus. Infectious disease evaluation changed the antibiotic from Unasyn to Cefazolin. The patient continued to improve and on day #5 the patient was thought to have improved adequately and was stable enough for discharge home on oral antibiotics as per Infectious disease.

Medical necessity is not established for inpatient hospital stay.

Inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. For the duration of the hospital admission, the patient was afebrile and had stable vital signs. The patient had clinical evidence of cellulitis; however, he did not have signs / symptoms to indicate presence of systemic sepsis, and he had not failed oral antibiotic therapy before presentation to the emergency room. The patient was afebrile, had stable vitals and had stable mentation and was able to tolerate oral intake. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient needed aspiration drainage of the elbow, but this does not require inpatient admission and can be done while being treated with antibiotics. The patient was hemodynamically stable and afebrile. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates.