Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Infection (cellulitis on abdomen). 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a teenage female with unremarkable medical history. She presented to the ED (emergency department) with a five-to-six-day-day history of lower abdominal swelling and erythema. The patient had no fevers and no history of skin infections. Her vital signs included temperature 37.5, heart rate 116, respiratory rate 20, blood pressure 145/73, and weight 108 kilograms. Examination was significant for no acute distress, regular heart rate and rhythm, clear lungs, tenderness and erythema left of midline with fluctuance, and non-focal neurologic exam. The area measured 5 centimeters by 7 centimeters. Laboratory evaluation revealed WBC (white blood cell) 
count 10.81 K (thousand) with 71.3% neutrophils, platelets 321 K (thousand), CO2 (carbon dioxide) 20, negative rapid viral screens. Abdominal ultrasound reveals complex nonspecific avascular collection in the area of interest. The patient was treated with clindamycin 600 mg (milligrams). Surgical consultation was obtained in the early morning Day #2 with recommendations for parenteral antibiotics and pain control, 
not yet ready for surgical intervention. Later in the morning, she was scheduled for the OR (operating room) for wound exploration, washout, and possible debridement. She underwent incision and drainage with removal of 6mL (milliliters) purulent material sent for culture, and wound packing. She was treated with IV (intravenous) fluids, antibiotics (cefazolin, clindamycin), Toradol and Tylenol for pain, advancing diet as tolerated, and daily dressing changes. The patient did well post-operatively with adequate pain management and stable vital signs. WBC (white blood cell) count improved to 6.31K (thousand). She tolerated regular diet and dressing changes. By Day #4, she was doing well, and the wound was without signs of infection. She was cleared by surgery. Screening labs were obtained, including a fasting lipid panel, hemoglobin A1C (glycated hemoglobin), liver enzymes, and thyroid studies. She was subsequently deemed stable for discharge to complete seven days of clindamycin. 

The Inpatient Hospital Admission was not medically necessary. 

The patient could have been safely managed at a lower level of care. Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient. This female patient presented with several day history of worsening cellulitis with eventual abscess formation. She was otherwise well, with no systemic symptoms (e.g., fever, chills). While it was not unreasonable to monitor her in the hospital for initial treatment with parenteral antibiotics and surgical intervention, she was overall hemodynamically stable with no evidence of impending sepsis, no systemic symptoms like fever, and no severe pain. She did not require acute inpatient admission and could have been safely managed at a lower level of care.