Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Inpatient Hospital

The patient is a male with a past medical history significant for human immunodeficiency virus (HIV), hepatitis C virus (HCV), hypertension, and hypothyroidism who presented to the emergency department with complaints of bilateral lower extremity swelling and pain.

The patient reported a two-month history of leg edema. In the last several days that preceded the day of admission, the patient noticed that his legs became red, warm, and much more painful. He also complained of subjective fever and chills. He reported nausea and vomiting that occurred on the day of admission following drinking orange juice.

At the time of the initial evaluation, the patient was afebrile, his heart rate was 78 beats per minute, respiratory rate 18, blood pressure 144/87, and oxygen saturation was 97%.
On exam, the patient had 2+ bilateral lower extremity edema as well as erythema in the lower extremities. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that white blood cell count was 12.4, hemoglobin 14.2, hematocrit 40.7, platelets 274. Sodium was 133, potassium 4.9, chloride 99, bicarbonate 25, blood urea nitrogen (BUN) 8, creatinine 0.8, glucose 96. Alkaline phosphatase was elevated at 200, aspartate aminotransferase (AST) 103, alanine aminotransferase (ALT) 62. Troponin and thyroid stimulating hormone (TSH) were normal.

The patient was admitted to the hospital with the diagnosis of chronic lower extremity edema with possible superimposed cellulitis.

The patient was recommended to keep his lower extremities elevated, to discontinue treatment with Amlodipine, and to start treatment with intravenous Clindamycin. Soon after admission, the treatment with intravenous Clindamycin was substituted with oral Cefazolin. Instead of Amlodipine, the patient was started on Lisinopril for blood pressure control.

During the hospital stay the patient underwent a lower extremity venous duplex study that ruled out deep vein thrombosis.

He also underwent an echocardiogram that demonstrated left ventricular ejection fraction was greater than 50% with no pericardial effusion and normal systolic function.
Chest x-ray showed no cardiomegaly, no vessel congestion.

During the hospital stay, the patient's clinical condition remained stable, and the patient was discharged home.

The health plan's determination is upheld.

Based on the review of the medical records, the degree of the patient's symptoms was relatively mild. It was not completely clear if the patient had acute cellulitis or the skin changes were related to hyperpigmentation in the setting of chronic lymphedema. This patient was afebrile and hemodynamically stable and had only mildly elevated white blood cell count. The patient responded to the treatment very quickly and was able to be transitioned to oral antibiotics within a very short period of time after admission. The patient had no evidence of deep vein thrombosis or any other clinical condition that would necessitate admission at the acute inpatient level of care.

This patient had an HIV infection; therefore, he was immunocompromised. Because of that, initiation of intravenous antibiotics at the time of admission was reasonable, since the patient was suspected to have acute cellulitis in the lower extremities. However, the rapid improvement in the symptoms prompted the fast transition to the oral antibiotic.
Therefore, neither the severity of the patient's condition nor the complexity of the services provided would rise to the level of acute inpatient care.