Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Toe infection
Treatment: Inpatient emergency admission
The health plan denied the inpatient emergency admission.
The health plan's determination is upheld.

The patient is a male with a history of diabetes, hypertension, peripheral neuropathy, fatty liver, and methicillin-resistant staphylococcus aureus (MRSA) infection of the right foot. He presented to the emergency room after a traumatic wound between the 1st and 2nd toe of the left foot about a week ago and now a two-day history of 1st toe swelling, chills, and diaphoresis. The vital signs were notable for a blood pressure of 173/98 millimeters of mercury (mmHg) and a pulse of 100 beats per minute (bpm), but he was afebrile. He was alert and in no acute distress. The physical exam was remarkable for swelling originating from the left great toe extending to the mid foot and a small amount of purulent discharge from the plantar surface of the toe. Labs revealed a glucose of 298, a bicarbonate of 21, and a white blood cell (WBC) count of 10,900. A left foot film showed soft tissue swelling of the 1st and 2nd toes consistent with cellulitis, and a bony fragment off the 2nd toe. Intravenous antibiotics were administered. The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with intravenous antibiotics and Lovenox for deep vein thrombosis (DVT) prophylaxis. The next day, the infectious disease consultant evaluated the patient and noted that the patient reported much improvement of his symptoms. It was also noted that no blood cultures were done before starting antibiotics, and that the wound was not amenable to culturing. Magnetic resonance imaging (MRI) was recommended along with continuation of the antibiotics. The MRI was performed later that day with findings consistent with a possible early abscess and osteomyelitis. The vascular surgeon saw the patient as well. The possible need for a toe amputation was discussed, but the patient demurred as there was already considerable improvement on antibiotics. The remainder of the stay was clinically uneventful, and the patient was discharged.

At issue is the medical necessity of the inpatient hospital admission. The health plan's determination of medically necessity is upheld in whole. The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no fever, hemodynamic instability, mental status changes, evidence of soft tissue necrosis, or severe metabolic disarray. In addition, there was rapid improvement with just antibiotics, obviating the need for surgical intervention. Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at an alternate level of care.