Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders-Cellulitis
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is a patient with a history of attention deficit hyperactivity disorder and migraines who was brought in complaining of a painful pustular lesion on the dorsum of his right foot. The family was on vacation to the Dominican Republic two weeks prior to admission where the patient was walking barefoot in the grassy areas and exposed to insects. Patient describes the wound that started as three small pruritic pimple-like lesions which he scratched until they popped. A week later the lesions became pustular and painful causing the patient to have difficulty bearing weight so the mother gave amoxicillin 3 tablets (unknown dosage) every 6 hours for one day which reduced the size of the lesion. A few days later the pain and the pus returned. One day prior to admission the pain progressed to an 8/10 and the patient began walking with a limp. Physical exam was pertinent for being in acute distress, obesity, and annular lesions on the dorsum of his right foot which turned into ulcers. Labs were ordered. Right foot X-ray revealed soft tissue swelling without fracture or focal bony lesions. Patient was started on intravenous fluids (IVF), Clindamycin and Toradol. Assessment was cellulitis of the foot with underlying bullous impetigo. He was admitted for intravenous (IV) antibiotics and further management. Surgeon consulted and documented cellulitis/abscess from insect bites, afebrile with normal vitals. Patient was placed on IV Vancomycin. After 2 doses he was switched to oral Keflex. The day after admission the patient had a decrease in swelling, but he was unable to bear weight on the right foot. He continued with IV antibiotics and pain management until the following day when he was able to walk on his right foot. He was discharged home on a 10-day course of PO Keflex and instructed to follow up with his primary medical doctor.
The requested health service/treatment of inpatient stay was not medically necessary for this patient. This patient presented with a lesion sustained 2 weeks prior that was progressively worsening. He did not have any fever, markedly elevated inflammatory markers, or unstable vital signs to suggest bacteremia/sepsis, nor was he given a trial of oral antibiotics as an outpatient. Upon presentation he did have pain and a limp, but his laboratory studies were unremarkable with a normal white blood cell count (WBC) and mildly elevated C-reactive protein (CRP). His condition at admission did not seem to warrant higher intensity of services or highly technical or skilled care. He was seen by a surgeon who noted no drainable pus present on exam or ultrasound, and an X-ray that revealed soft tissue swelling without fracture or focal bony lesions. These findings correlate with a favorable outcome and expected improvement within 24-48 hours on IV antibiotics. He indeed went on to have an uneventful course that very quickly responded to IV antibiotics and permitted transition over to PO antibiotics after 2 doses of IV antibiotics. He did not require any surgical intervention. He was discharged within 48 hours. The mainstay of his care was administration of IV antibiotics for less than (<) 24 hours. His findings correlate with favorable outcome and expected improvement with IV antibiotics. This patient did not meet any criteria for inpatient admission for cellulitis. He is not less than (<) 6 months of age, is not immunocompromised or immunosuppressed, there was no hemodynamic instability, no suspicion of necrotizing soft tissue infection or bacteremia. His disease was not described as extensive, he did not have high fever, nor did he fail outpatient treatment. His WBC count was < 15,000. His CRP was mildly elevated. Based on these criteria, inpatient hospitalization was not required or warranted.