Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female.

The emergency room provider documented the following: Patient has insulin-dependent diabetes mellitus and history of cellulitis/abscess. She states she has had new abscesses on her buttock and under her pannus for the last week. She also has had urinary frequency and urgency and bilateral lower back pain consistent with urinary tract infections in the past. She denies fevers, vomiting, diarrhea, rashes, coughing, and other associated complaints. Review of systems was negative except as described above.

The patient's Physical Examination in the emergency room documented the following: Skin was warm, dry, no rashes. There was a raised, sinused, semi-fluctuant area to the right lower quadrant with a large patch of surrounding erythema. There was a fluctuant area to the left buttock at the gluteal fold without surrounding erythema.

The patient continued to exhibit tachycardia while in the emergency room. At the time of admission to an inpatient level of care, the following were documented: Vital Signs were BP (blood pressure) 121/94; Pulse 112; Respiratory rate 18; Temperature 97.0; Pulse Oximetry 97%; Weight 111.58 kg (kilograms); Height 5 feet 11 inches; Pain 8/10. Temperature was 100.

The admitting Provider documented the following: The patient's chief complaint was abscess on abdomen and left buttock. Her History of Present Illness included past medical history of Hypertension, Diabetes mellitus, Dyslipidemia, COPD (chronic obstructive pulmonary disease), chronic low back pain, anxiety, depression, chronic cigarette smoker. She came to the hospital complaining of having abscess on her lower abdomen and left buttock. Patient said it started about one week ago and she thinks it is getting bigger. She has a lot of pain around the area of abscess/swelling. She had a low grade fever at home. She did not know how she got the abscess. She denied any trauma or cut to the abscess area. Denied any shortness of breath, coughing, nausea, vomiting, abdominal pain, diarrhea, constipation, urinary problem. The patient had similar abscess about many years ago at her tail bone, which needed debridement. The patient said her blood sugar is well-controlled and always less than 200 mg/dl (milligrams per deciliter). She said she is compliant with her medication.

In the ER (emergency room), blood test show mid leukocytosis of 16K (thousand). Normal lactic acid level. CMP (comprehensive metabolic panel) unremarkable. Patient had low grade fever of 100 in ER (emergency room). ER (emergency room) physician had done incision and drainage of the abscess on lower abdomen and left buttock and placed sterile dressing with bacitracin ointment. Wound culture and blood culture were pending. She was treated with IV (intravenous) vancomycin in ER (emergency room). Hospitalist service called to continue treatment.

Findings showed white blood cells 16.67. The patient had a bedside incision and drainage in the emergency room. Infectious Disease was consulted and the patient was treated with intravenous Rocephin and vancomycin. Wound culture grew group B hemolytic Streptococcus, methicillin-susceptible Staphylococcus aureus, and Enterococcal faecalis. Blood culture was negative.

The patient left against medical advice prior to final culture sensitivities being reported. The patient was given a prescription for Cefdinir.

No, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Continued inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk as based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition.

The patient had stable vital signs. Patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. Patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered  / work up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital. During the above duration, the patient's diagnosis had been established clinically and based on the results of the investigations.

The patient's temperature and other vital signs were not representative of sepsis during this time. General and systemic examination was normal or at baseline. The patient was able to eat food, drink fluids and take oral medications. Although patient had pain, it was not intractable, and not noted to be amenable to appropriate oral treatment. Care rendered during this time was of low intensity, routine nursing and physician monitoring. No systemic findings such as high fever, shock, renal or liver failure or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning and the patient's medical problems did not pose an immediate high risk of deterioration.

The patient was not in acute distress and in view of these facts of the patient's clinical status, the illness was in the post-acute phase and ongoing risk of deterioration was low since diagnosis had been established and patient was responding appropriately to the treatment. The patient did not have any acute complications during this time. No high frequency, high complexity, or high risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness in the post acute phase and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates.

In view of these findings and generally in accordance with MCG (Milliman Care Guidelines) guidelines therefore, the ongoing inpatient level of care for the above duration was not medically necessary.

During the above duration, patient's main clinical need was administration of IV (intravenous) antibiotics and this could have been safely and effectively managed at a lower level of care.  The intensity, acuity and severity of the clinical condition of the patient during this period was medically appropriate for a lower level of care.