Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders/Cellulitis/Right Upper Extremity Pain and Swelling (Abscess), History of (and Active) Intravenous Heroin Use.
Treatment: Inpatient Hospital Services.
The health plan denied the requested Inpatient Hospital Services as not medically necessary. 
The health plan's determination is overturned.

This case involves a man with intravenous (IV) heroin use, who was admitted with right upper extremity swelling and pain for four days. The patient also complained of chills. He injected heroin in the arm. He also complained of left foot pain, and being unable to stand on his feet without trauma. On exam, his temperature was normal, his heart rate was 90 beats per minute (bpm), and his blood pressure was 135/98 millimeters of mercury (mmHg). A physical exam showed the patient in painful distress. His extremities revealed right elbow and forearm erythema and edema warm to the touch, with no purulence drainage. The right foot was also edematous, with mild erythema over the dorsum of the foot and tenderness to the touch. The rest of the exam appeared unremarkable.

The patient was admitted to the hospital with upper extremity cellulitis and was started on Vancomycin and Zosyn. Pain control was provided with IV Morphine, and arm elevation was instituted. Blood cultures were drawn in the emergency department. Additionally, the medical team ordered a computerized axial tomography (CAT) scan of the lower extremity, as the x-ray showed no fracture. Psychiatry was consulted for a detoxification plan.
Over the next 24 hours, the patient was continued on broad-spectrum antibiotics. The blood culture showed no growth. An infectious disease consultation was requested. IV fluids were discontinued, as the sodium levels improved. The patient was initiated on Methadone for the prevention of narcotic withdrawal. Duplex ultrasound of the right upper extremity was obtained, showing an occlusive thrombus in the right basilic and cephalic veins consistent with thrombophlebitis. There was no evidence of a deep vein thrombosis (DVT). The patient was also given Clonidine and Hydroxyzine for withdrawal symptoms. By the next day, the sodium was normal, and the patient denied chest pain or shortness of breath. The next day, the medical team decided to treat the patient with low-dose Apixaban for 30 days for thrombophlebitis. The plan is to discharge the patient and resume Suboxone on discharge. The infectious disease consultant recommended stopping the current antibiotic regimen and switching to Teflaro 600 milligrams (mg) IV every 12 hours. The medical team documents the resolution of the erythema but with residual induration over the brachiocephalic vein. The right foot pain resolved. The patient remained afebrile with normal labs.
The patient was released on an oral antibiotic regimen, including Augmentin and Bactrim, for seven days.
The question is the medical necessity for an inpatient level of care.

I overturn, in whole, the health plan's determination of medical necessity.

Yes. Inpatient hospitalization is warranted in this case. Based on the provided documentation, inpatient hospitalization was indicated for this patient. Based on the provided documentation, this was an active IV heroin abuser, who presented to the hospital with 10 out of 10 pain, and signs of infection of both the right upper extremity and the foot. The patient was initiated on broad-spectrum antibiotics while awaiting blood culture results. Concurrently, the patient was experiencing hyponatremia and had elevated liver enzymes, which require ongoing monitoring. The patient's pain levels were poorly controlled, requiring treatment with Methadone, IV Morphine, Clonidine, and Hydroxyzine. He had active IV drug use, causing significant tolerance to pain medications, and required escalating doses. As a result, the presentation was too complicated to expect rapid resolution of the symptoms within the observation timeframe. Inpatient admission was indicated.