Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Infection. 
Treatment: Inpatient Admission. 

The health plan denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female with a history of folliculitis who was admitted to the hospital for cellulitis. The patient presented to the Emergency Department (ED) with an area of swelling, erythema and pain in her left upper inner thigh. In the ED she was noted to be without fever and on exam she was not in acute distress. An ultrasound was done and was consistent with cellulitis in the ED. She had laboratory studies completed and she received intravenous antibiotics. The laboratory values obtained included a normal white blood cell (WBC) count of 12.9. The patient was subsequently admitted for monitoring and continued with the administration of intravenous (IV) antibiotics. The patient underwent an operative incision and drainage procedure. She was subsequently discharged 2 days later. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The patient was not immunocompromised. There was no orbital cellulitis or cellulitis over an implanted device. There were no signs of a systemic illness in the physical examination of the patient. The patient could have started on oral antibiotics and followed up the next day with her primary care physician (PCP) especially after the area was drained in the operating room (OR). 

The requested health service and treatment of an inpatient admission was not medically necessary for the patient. The treatment of bacterial cellulitis relies on the appropriate use of antibiotics depending upon the type of patient and the presence of a systemic disease. Tenderness without an abscess, fever and erythema are typical of most types of superficial cellulitis. The location of the infection alone is not an ominous clinical feature requiring IV antibiotics and a hospital admission. This is especially true when there is no evidence of systemic inflammatory response syndrome (SIRS), or any concomitant immunodeficiency. After antibiotics are initiated, routine outpatient follow-up is the standard of care when the patient is well appearing. The laboratory evaluation did not show signs of overwhelming sepsis and her WBC count was not significantly elevated. 

Concerns for a systemic infection leading to the Systemic Inflammatory Response Syndrome (SIRS) would have been a reason for admission. SIRS is defined by:
"The presence of two or more of the following criteria, one of which must be an abnormal temperature or leukocyte count. The criteria are as follows; a core temperature greater than (>)38.5 degrees () Celsius (C) or less than (<) 36C which must be measured by a rectal, oral or central catheter probe; tachycardia, defined as a mean heart rate which is > the standard deviation (2SD) above normal for age in the absence of external stimulus, chronic drugs, or painful stimuli, or an otherwise unexplained persistent elevation over a 0.5 to a 4 hour time period or for children < 1 year old; bradycardia, defined as a mean heart rate that is < the 10th percentile for age in the absence of external vagal stimulus, beta-blocker drugs, or congenital heart disease, or an otherwise unexplained persistent depression over a 0.5 hour time period; a mean respiratory rate > the 2SD above normal for age or mechanical ventilation for an acute process not related to underlying neuromuscular disease or the receipt of general anesthesia; the leukocyte count is elevated or depressed for age (not secondary to chemotherapy-induced leukopenia) or >10 percent (%) immature neutrophils."
The patient did not meet the above criteria for SIRS.