Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient hospital stay
Issue: Medical necessity of the inpatient hospital stay
The health plan's determination is upheld in whole.

The patient has a past medical history significant for asthma and intravenous drug abuse (quit 1 year before the presentation) who presented to the hospital with a 3-day history of worsening left leg pain and redness that was associated with nausea and vomiting.
According to the history and physical (H&P) note, the patient was admitted for treatment of cellulitis several weeks before the current presentation but left the hospital against medical advice (AMA). However, at the end of that hospitalization, received a prescription for Amoxicillin, which the patient did not take.
When the patient was seen by the admitting physician, the temperature was 97.8F, heart rate was 78 beats per minute (bpm), respiratory rate 18, blood pressure 110/64, and oxygen saturation 98% on room air.
The patient appeared to be a well-developed, well-groomed, well-nourished individual who was in no acute distress.
The airway was patent and breath sounds were equal, with good air movement. Respirations were non-labored. Lungs were clear to auscultation bilaterally. The cardiovascular exam revealed a regular rate and rhythm. Pulses were normal.
In the right lower extremity the patient had mild erythema, in the area that was located in the mid part of the shin and measured 8cm x 4cm. There was some skin ulcer in that area.
In the left lower extremity the patient also had erythema, local redness, tenderness, and ulceration that was measured 1 by 2cm in the mid-shin. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 6.3, hemoglobin 10.8, hematocrit 33.5, platelets 253. The patient's sodium was 140, potassium 3.5, chloride 100, bicarbonate 30, blood urea nitrogen (BUN) 10, creatinine 0.8, alkaline phosphatase 129.
X-ray of the left foot demonstrated soft-tissue edema but no acute osseous abnormality. X-ray of the left and right tibia/fibula showed bilateral soft tissue edema.
The patient was admitted to the hospital with a diagnosis of cellulitis of the lower extremities. The patient received treatment with intravenous Vancomycin. Blood cultures were obtained.
Subsequently, the patient received treatment with intravenous Clindamycin. Patient was seen by a surgical service and was recommended no further intervention.
Since the patient remained in stable clinical condition, the patient was discharged home with a recommendation to follow-up with medicine and dermatology clinics.
The hospital stay was not medically necessary for this patient at the acute inpatient level of care 
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Based on the review of the medical records, there was no evidence of a failure of outpatient therapy, since the patient did not take oral antibiotics that were prescribed, there was no evidence of limb-threatening infection, rapidly progressing infection, high-risk comorbid conditions such as immunocompromised state, or bacteremia.
The review of the medical records did not demonstrate that the patient had altered mental status, hemodynamic instability, or necrotizing soft tissue infection.
There was no need for a surgical procedure not amenable to outpatient or emergency department care, this was not a case of cutaneous gangrene, the patient did not have severe pain requiring acute inpatient management, or the inability to maintain oral hydration.
Taking into consideration all of these facts, there is no reason that the patient required admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. The admission at a lower level of care was justified.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.