Appeal type: Medical necessity
Decision: Upheld

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


The patient has with multiple medical problems, including coronary disease, who presented to the hospital with bilateral lower extremity pain and swelling. The patient reported three previous episodes of cellulitis during the preceding year. He complained that his legs were swollen, red, and buckled when he walked. The patient admitted to drinking alcohol several times per week and had a history of alcoholism. He reported compliance with aspirin, Synthroid, Lipitor, and Lopressor.
Vital signs on arrival included a normal temperature of 36.9 degrees Celsius (C), blood pressure 152/65, and respirations of 18. On exam, the cardiopulmonary exam was unremarkable. The patient had a full range of motion of the joints, bilateral lower extremity edema with erythema of the left greater than right extremity, and venous stasis changes.
A computed tomography (CT) angiogram of the chest was obtained, showing no acute pulmonary disease. A venous duplex of the lower extremities showed no deep vein thrombosis (DVT). Labs were obtained, showing a steady hemoglobin, stable electrolytes, renal function, and liver function tests (LFTs). The white blood cell count is normal at 5.05.
The medical team documented that the principal diagnosis was chronic knee pain with ambulatory dysfunction. They obtained an x-ray of the knees and consulted physical therapy,  empiric antibiotics for cellulitis of the lower extremity were started and infectious disease consulted.
An infectious disease specialist assessed the patient and documented cellulitis with lower extremity edema as a principal diagnosis. The pictures of the legs show bilateral chronic venous stasis changes no streaking. The left leg is slightly larger than the right. The infectious disease (ID) specialist added aztreonam on top of the vancomycin.
The following day, the patient remained afebrile. He denied nausea, vomiting, diarrhea. He tolerated the antibiotic therapy without difficulty. The rest of the vital signs remained stable. The exam was unchanged. There were no repeat labs. The treatment was continued without any significant changes.
The vital signs remained stable, with no sign of sepsis. The picture of the legs was unchanged. Physical therapy worked with the patient. The infectious disease specialist reassessed the patient, noted a normal white blood cell count, normal electrolytes, and renal function, and switched the antibiotics to oral doxycycline. The medical team reassessed the patient and documented still awaiting x-ray results of the knees, with an inference that the patient may have been refusing. The physical therapist  noted that the patient ambulated 80 feet times (x) 2 with a rolling walker and recommended 3-5 times a week physical therapy for 25 minutes per session.
By hospital day 4, the hospitalist team reassessed the patient on rounds in the morning and noted he was complaining of bilateral knee pain. Repeat lab results were completely stable.
An orthopedic surgery consult was requested due to chronic complaints of left knee pain for three years, worsening over the preceding three months. The x-ray of the knees showed no acute osseous or articular abnormality mild right knee degenerative changes. The orthopedic surgeons recommended the computed tomography (CT) scan of the left knee without contrast to rule out a lateral tibial plateau fracture. The CT scan was reviewed by orthopedic surgery and showed no fracture or dislocation and only mild arthritis. No emergent orthopedic intervention was deemed necessary, and the patient was instructed to follow up in 2 weeks.
The patient remained in the hospital and the medical team recommended discharge from the hospital. The patient declined to leave the hospital for psychosocial reasons. He signed and noted that he was medically cleared for discharge. He was released from the hospital on oral doxycycline therapy. He had to be escorted with security out of the hospital. He was offered multiple outpatient resources, which he refused.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for the patient for the specified dates.
The medical record and multiple images of the patient's lower extremities were reviewed. There is evidence of chronic venous stasis and questionable cellulitis. There is no evidence of sepsis, necrotizing fasciitis, deep tissue infection, fractures, or need for surgery. There is no evidence of compartment syndrome due to injury. Based on the documentation, there is no clear evidence that the patient was on active antibiotic therapy and had failed treatment. There is documentation of previous cellulitis infections over the preceding year, but none that the current infection had failed outpatient treatment. As a result, clinical indications for inpatient admission are not satisfied. The patient had normal vital signs, a normal white blood cell count, no evidence of deep vein thrombosis (DVT), and no evidence of systemic spread of infection.
An inpatient stay was not medically necessary. Care could have been provided at a lower level.