Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders - Cellulitis
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with no past medical history who presented to the emergency department (ED) for evaluation of right-hand pain and swelling. His symptoms started one day before the presentation. The swelling was located around the dorsum of the right hand and was associated with redness. The day before his presentation, the patient went to see his primary care physician who gave him a prescription for Augmentin for cellulitis. The patient stated that he marked the area of redness, and despite taking Augmentin, the redness was spreading past the marked border. The patient could not recall any injury to the right hand or any wounds in the area.
The review of systems was negative for fever, chills, chest pain, shortness of breath, upper extremity edema, numbness or tingling, abdominal pain, nausea, vomiting, recent travel, or sick contacts. The laboratory evaluation revealed that the white blood cell count was 7.8, with a hemoglobin of 15.0, a hematocrit of 46.0, and platelets of 205. The sodium was 137, with a potassium of 4.4, a chloride of 101, a bicarbonate of 25.8, a blood urea nitrogen (BUN) of 11, a creatinine of 0.76, and a lactic acid of 1.63. The liver function tests were normal. An x-ray of the right hand showed no fracture or dislocation. The patient was admitted to the hospital with right-hand cellulitis. He was started on intravenous (IV) antibiotics. The patient was seen by an infectious disease specialist who recommended the continuation of treatment with IV antibiotics and a trial of steroids for two doses.
As a result of the treatment, his symptoms of cellulitis significantly improved within the first 48 hours, and the patient was transitioned to outpatient care with a recommendation to take oral antibiotics, Keflex and Bactrim, for 7 days.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld.
The requested health service/treatment of inpatient admission was not medically necessary for this patient.
In general, admission at the acute inpatient level of care is indicated for patients with cellulitis that failed outpatient therapy, in cases of limb-threatening infection, or rapid progression of the infection that necessitated high-intensity monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus, or liver cirrhosis.
Admission at the acute inpatient level of care is also indicated for patients with cellulitis and bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection or oral cellulitis, or when patients need a surgical procedure not amenable to outpatient or emergency department care, cases of cutaneous gangrene, or when patients have severe pain requiring acute inpatient management, inability to maintain oral hydration, in cases of compartment syndrome, or some other conditions that were not relevant to this clinical case.
The review of the medical records did not show evidence that the patient had any of the circumstances justifying admission at the acute inpatient level of care for treatment of cellulitis.
Specifically, it was mentioned several times in the patient's records that he failed outpatient treatment. Failure of outpatient treatment is considered progression or no improvement after an adequate trial of a minimum of 48 hours of oral antibiotic. Based on the medical records, the patient started to take Augmentin only one day before his presentation to the emergency department. Therefore, it is not fair to say that he failed outpatient treatment, and inpatient care was not medically necessary.