Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with past medical history of hyperlipidemia, gastroesophageal reflux disease (GERD), anxiety, alcohol abuse and usage of tobacco - vaping. The patient presented with complaints of progressive erythema and swelling of upper extremities after a history of a cat bite the prior day. The patient was initially evaluated at urgent care after the cat bite and was started on an antibiotic and local cream to the bite site. The patient did not feel that the symptoms improved and so she presented to the emergency room for further treatment. 
Evaluation in the emergency room showed the following vitals: temperature (T) 96.5 Fahrenheit (F), blood pressure (BP) 116/67, and pulse (P) 104. Labs showed a white blood cell (WBC) count at 7.8 thousand, blood urea nitrogen (BUN) 9, creatinine 0.6, platelet 234, and lactate 2.3. X-rays of the hand and forearm did not show subcutaneous air. The patient was started on treatment with Clindamycin and Motrin and was admitted to inpatient hospital care. The patient was also started on intravenous fluids and treated with thiamine and folic acid and was started on a Clinical Institute Withdrawal Assessment (CIWA) protocol and intravenous Ativan. Infectious disease and surgical consult were requested also. The patient continued to improve and was subsequently discharged.

The inpatient medical admission was not medically necessary.

The patient presented with concern for cellulitis after a cat bite, however the patient was afebrile on admission and had stable vital signs except for mild tachycardia. Clinical evaluation and review of lab results did not show any findings to indicate the patient had sepsis / septic shock that may need inpatient admission for treatment. Additionally, the patient was not immunocompromised, the area of involvement in this case was not located over a prosthesis or implanted device and the patient did not have involvement of the eye (orbit). In view of this, inpatient medical admission was not needed for the requested duration. The patient required treatment with antibiotics, however this could have been effectively and safely managed at a lower level of care. The patient had stable vital signs and routine labs remained at baseline. 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 the patient had pain, it was not intractable, and 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. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness 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.