Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall; possible infected wounds
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with medical history of osteomyelitis, epidural abscess status post laminectomy, intravenous drug abuse, chronic indwelling Foley catheter for chronic urine retention, and history of motor vehicle accident for which he required multiple skin graft placements. The patient was transferred for emergency evaluation after a fall from the bed while attempting to transfer to his wheelchair. Additionally, there was concern for infected wounds of the skin graft site. On evaluation in the emergency department, vital were the following: temperature (T) 97.5 degrees Fahrenheit (F), blood pressure (BP) 97/50, pulse (P) 47, respiratory rate (RR) 18, and pulse oximetry 95 percent. X-ray of the left femur, knee and tibia fibula did not reveal fracture. X-rays of the radius and ulna on both sides showed soft tissue swelling without definitive evidence of osteomyelitis. Labs showed white blood cell (WBC) at 7.5 thousand (k), hemoglobin 11.8, platelet 400, blood urea nitrogen (BUN) 8.6, and creatinine 0.6. The patient was evaluated and started on intravenous fluids and intravenous antibiotics (clindamycin, vancomycin) and intravenous analgesics due to concern for cellulitis. Consultation was requested from surgery and infectious disease and the patient was admitted to hospital stay for further treatment. The patient continued to improve and was discharged.

The inpatient medical admission was not medically necessary.

The patient presented for evaluation after a fall and there was concern for infection - cellulitis at the wound sites. The patient however was afebrile on admission and had stable vital signs. 
Clinical evaluation and the review of the lab results do not show any findings to indicate 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 above duration. The patient required treatment with antibiotics, however this could have been effectively and safely managed at a lower level of care. The patient was afebrile and had stable vital signs. The 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 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. 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 were routine, ongoing inpatient care was not medically necessary during this time. Therefore, the ongoing inpatient level of care for the above duration was not medically necessary.