Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis of Right Foot

Treatment: Inpatient admission	

The insurer denied coverage for inpatient admission

The denial is upheld 

This case involves a patient who presented to the emergency department.  The patient complained of pain and swelling to the right great toe since a day prior.  The patient denied trauma or other injury and had comorbidities consisting of coronary artery disease involving the native heart without angina pectoris, osteoporosis, permanent atrial fibrillation, prediabetes, and primary hypertension.  Under the review of systems, the patient was positive for arthralgias, joint swelling, and color change to the skin.  Erythema was noted on physical examination the assessment confirming cellulitis to the right great toe. The plan was to admit the patient for further work-up and pain management.  This would include x-rays, oral antibiotics, and laboratory testing.  The patient rated their pain an 8/10 with orders placed for tramadol and Keflex. The patient's vital signs were stable, and the patient was negative for COVID.  The patient had a sepsis risk score of 1.12 indicating very low or low risk.  The patient's B-type natriuretic peptide (BNP) result was elevated at 292 with creatinine kinase normal at 57.  

The report stated the patient lives in a shelter, ambulated with a walker for up to 2 blocks, and had no home care.  The patient did not smoke, drink alcohol, or abuse drugs.  On examination, the patient's pulse rate was 92, respirations 16, blood pressure 172/81, with decreased expiration breath sounds, intact dorsal pulse to the right foot, and a mildly warm right foot.  Additional laboratory results showed normal white blood cell count, with elevated chloride at 110, elevated alkaline phosphatase at 109, and elevated total bilirubin at 1.4.  X-rays of the right foot showed no acute findings.  

The Milliman Care Guidelines (MCG) 27th Edition have indicated that some patients may be appropriate for observation care while others require inpatient admission.  In terms of patients with cellulitis, unless they are hemodynamically unstable, have altered mental status that is severe or persistent, have a limb threatening infection, or clinical presentation (e.g., acuity of infection, rapidity of progression) or treatment regimen is judged to require intensity of patient monitoring (e.g., vital sign measurement, checks for infection progression, laboratory testing) that cannot be provided at other than inpatient level of care, bacteremia, suspected necrotizing soft tissue infection, severe oral or head and neck cellulitis, orbital infection, pre-septal or perineal infection that is severe progressive, severe pain requiring acute inpatient management, the inability to maintain oral hydration that persist after observation care, or compartment syndrome monitoring, they are not considered suitable candidate for inpatient management.  Patients with gout and hyperuricemia may be preferred for emergent evaluation or management of septic arthritis, and those who have congestive heart failure, may be admitted various reasons to include dyspnea that persist despite observation care.  The information provided for the review indicated that the patient's condition improved after treatment with no evidence of unstable blood pressure, severe abnormal testing, tachycardia, or difficulty breathing for more than observational level of care.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient services is not substantiated.