Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis.
Treatment: Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is overturned.

The patient is an adult female. She has a long-standing history of IV (intravenous) drug abuse, PVD (peripheral vascular disease) and chronic recurring cellulitis. She had been previously seen in the emergency room for pain and swelling to the lower extremities, but with less extensive wounds than this admission. At that time, the patient left AMA (against medical advice) and was prescribed Bactrim 160 mg (milligrams) PO (by mouth) and Keflex 500 mg (milligrams) PO (by mouth).

The patient returned with increasing pain, swelling, and redness of left leg and feeling like "my leg is going to fall off." Evaluation in the emergency room, revealed patient tearful, appeared much older than stated age, chronically deconditioned, and malnourished. On examination, the patient was noted to have a non-healing, stage 3 wound extending from the top third to lower third of the medial calf of the right lower extremity, without ankle or knee joint involvement, approximately 15x7 cm (centimeters); non- healing, stage 3 wound extending from the top third to lower third of the medial calf of the left lower extremity approximately 12x7 cm (centimeters). Left foot with bright pink cellulitis of the dorsum, edema of the left foot, bright red erythema of the left medial knee extending from the knee to the medial aspect of the thigh of the right lower extremity with questionable developing vesicles concerning for shingles.

CT (computed tomography) of the patient's bilateral lower leg showed bilateral cellulitis. Labs showed elevated WBC (white blood cell) count 12.1 with left shift, hyponatremia at 129, UA (urinalysis) positive for UTI (urinary tract infection) and UD (urine drug screen) positive for opiates, cocaine, and amphetamines. The patient was given Ofirmev x 1, Valtrex x 1, and Zosyn 3.375 mg (milligrams) x 1. She was admitted inpatient and was followed by ID (infectious diseases) and surgery.

The Inpatient Hospital Admission was medically necessary.

After 24 hours on IV (intravenous) Vanco and IV (intravenous) Zosyn, the patient's left leg demonstrated extension of the exquisitely tender erythema to the posterior aspect of the distal thigh with some clearing anteriorly noted.

On day three of the admission, cultures grew Group C strep. IV (intravenous) Vanco was discontinued, and IV (intravenous) Zosyn was continued. The patient developed fluid-filled vesicles on dorsal surface of left foot, and erythematous blanchable area on medial left thigh continued to be painful. Punch Biopsies were done on medial left thigh area and dorsal surface of left foot to rule out pemphigus vulgaris or other autoimmune skin disorders. She was started on IV (intravenous) Solu-Medrol 40 mg (milligrams) to assess if it improved symptoms.

The patient signed out against medical advice and the left the facility. Augmentin was ordered for the patient to continue on outpatient basis.

Inpatient admission was medically appropriate for this patient due to the following reasons:
The patient had failed outpatient oral antibiotic treatment for the same problem given previously. She had now presented with the same wounds that had not healed and had progressed in comparison. The patient presented with extensive non-healing wounds on the extremities, concerning for extensive infection and possible limb-threatening infection. The patient was at risk of fulminating infection, sepsis, and loss of limbs, if not treated appropriately and expeditiously. Treatment for such wounds would require administration of IV (intravenous) antibiotics for 7 to 14 days, depending on the clinical response. The patient would also need debridement of the wounds and surgical evaluation. The patient was likely noncompliant to treatment, and admission to the hospital would allow for appropriate and continued treatment for this severe infection.