Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 
 
This case involves an adult male with a history of polysubstance use disorder to include intravenous (IV) methamphetamine/heroin who presented to the emergency department complaining of numerous skin lesions to the upper and lower extremities.  He endorsed injecting into his arms and under the skin in his lower legs with the assessment noting numerous scabbing lesions on the arms and legs and an abscess to the left calf.  There were concerns that the patient may have cellulitis with methicillin-resistant Staphylococcus aureus (MRSA).  The patient denied fevers, nausea, vomiting, chest pain, shortness of breath, or abdominal pain.  He was agreeable to inpatient admission.  The examination noted a temperature of 96.6, respirations 16, with blood pressure 126/56 and a heart rate of 60.  The patient was hemodynamically stable and afebrile with suspected cellulitis and high risk of MRSA given his history of intravenous drug use.  The report stated that the patient had a poor follow-up plan and there were concerns for noncompliance.  The plan was to admit for intravenous antibiotics given the patient was at high risk.  As of the following day, the patient explained that he was going home. His IV was removed and he subsequently walked off the unit independently and elopement was reported per provider request.  

According to the Milliman Care Guidelines, clinical indications for admission to inpatient care for those individuals with suspected cellulitis include those who are hemodynamically unstable, have altered mental status that is severe persistent, those who have limb threatening infections, when there is clinical presentation (eg, acuity of infection, rapidity of progression) or treatment regimen is judged to require intensity of patient monitoring (eg, vital sign measurement, checks for infection progression, laboratory testing) that cannot be provided at other than inpatient level of care, bacteremia, suspected necrotizing soft tissue infection, severe oral or head and neck cellulitis, orbital infection, preseptal or perennial infection that is severe progressive, severe pain requiring acute inpatient management, inability to maintain oral hydration and need intravenous fluid support that persist after observation care, or when there is a need for compartment syndrome monitoring.  

The information provided for the review noted that the patient had evidence of cellulitis with a risk for MRSA.  While it was noted that the patient eloped, the initial admission was medically appropriate given the extent of the patient's condition.  Monitoring the patient's vital signs and infection progression is within the standard of care given that the patient's history of drug use increases risk for other issues to include sepsis, infectious diseases, and the need for further work-up and care to prevent any deterioration in his overall health.  Given the provided information, the inpatient stay was medically necessary, appropriate and within the standard of care.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.