Appeal type: Medical necessity
Decision: Upheld

Diagnosis Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

This patient presented with right arm swelling and erythema for 24 hours. Per his mother, he was swimming in a pool 2 days prior to the presentation but did not develop any swelling until the following day. On the day of presentation, his mother felt as if the redness was spreading up his arm. His mother also relates that his aunt accidentally shut the patient's arm in the door but the patient did not favor the arm afterwards. The mother reports that he has been eating, drinking and behaving at baseline. The patient's mother also states that the patient has otherwise been acting normal. There was no fever, and no chills. On exam, the child was noted to have the right hand/wrist with erythema and swelling extended to mid forearm.
Laboratory studies and imaging were ordered. The working diagnosis was cellulitis, rule out osteomyelitis, rule out fracture. In the emergency room (ER), the vital signs revealed a temperature of 97.9 degrees Fahrenheit (F), heart rate 119, respiratory rate 22, oxygen saturation (O2 sat) 100% on room air. Notable on exam was the swelling of the right hand/wrist with erythema extending to mid forearm. Laboratory studies that were done showed a complete blood count (CBC) with a white blood cell count of 17.9, C-reactive protein (CRP) was pending. Erythrocyte sedimentation rate (ESR) was negative. A blood culture was sent. Admission was requested for continuity of intravenous (IV) antibiotics and management of cellulitis to right forearm. The admission physical exam documented edema and erythema which extended from the thenar region all the way through the ventral portion of his right forearm with warmth to touch. There was no pain on palpation, no open lesions or rashes. The left arm had no evidence of swelling or erythema. The patient started on IV clindamycin every (Q)6 hours and Motrin as needed (PRN) for fever and pain. The patient was also started on a regular diet. The plan was for the patient to be discharged home when the erythema and edema of the right arm improved and he also demonstrated the ability to take by mouth (PO) antibiotics and the blood culture was negative for 48 hours. Overnight the patient did well. There were no fevers and the demarcated area of swelling/erythema had reduced significantly in size. He was cleared for discharge home to continue oral clindamycin as an outpatient and follow up with his primary medical doctor (PMD) in 1 to 2 days.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. Upon admission, he did not exhibit fever, markedly elevated inflammatory markers, or any drainable abscess that would require surgical intervention. These findings correlate with favorable outcome and expected improvement within 24-48 hours on IV antibiotics. He went on to have an uneventful course that very quickly responded to IV antibiotics and permitted transition over to PO antibiotics with discharge within 48 hours of admission. Generally accepted criteria for inpatient admission include hemodynamic instability, suspected necrotizing soft tissue infection, bacteremia, extensive disease, failure of outpatient treatment, high fever or perineal infection that is severe or persistent. This patient did not meet any inpatient criteria upon presentation. Inpatient level of care was not medically necessary.