Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin/Cellulitis/Left lower extremity swelling, pain and erythema
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is overturned.

The patient is a man with a past medical history of hypertension and hyperlipidemia. He presented to the emergency department with a complaint of left lower extremity swelling, pain, and erythema that started 2 days prior to this presentation. He was started on oral Keflex 2 days prior to presentation by an outpatient physician. He reported a fever and chills at home. It is also worth noting that he had cellulitis in the past and that same extremity, but it was "never so severe" per his report.
Vitals on presentation were a blood pressure (BP) ranging between 115/67 millimeters of mercury (mmHg) and 153/87 mmHg, a heart rate (HR) of 83 beats per minute (bpm), a respiratory rate (RR) of 20/minute and a temperature maximum of  37.3C. His oxygen saturation was 97% on room air. The physical exam showed a well-appearing gentleman. Cardiovascular and respiratory exam were normal. The musculoskeletal exam stated that the left lower extremity is warm to the touch. Erythema is noted anteriorly, and the lateral aspect of the ankle to below the knee. It was noted that the area was also edematous and tender to palpation. No calf tenderness was noted, and distal perfusion was normal. No other abnormal findings are noted on the physical exam. Laboratory examination showed a white blood cell count (WBC) of 8.0 with 21% bands. Lactate was 3.1. The basic metabolic panel (BMP) was essentially normal. COVID was negative. Radiographic examination with a computed tomography (CT) scan of the lower extremity was essentially negative for any concerning findings such as necrotizing fasciitis, osteomyelitis, or an abscess.
In the emergency department, the patient was started on Doxycycline and Ancef. The Keflex was discontinued. The patient was admitted to the inpatient service for continued management and treatment. It was noted on the admission note that he was ambulating, but with pain.
When the blood cultures resulted, they were noted to be negative. The patient was seen by physical therapy and recommended to be discharged home. On the day of discharge, he was deemed to be stable. The patient was discharged on oral antibiotics.
At issue is the medical necessity for the inpatient stay.

I am overturning, in whole, the health plan's determination of medical necessity.

Yes, the required treatment for this patient required an inpatient admission because adequate outpatient treatment failed. This determination is made based on the provided electronic medical records. This patient essentially presented to the emergency department with cellulitis of the left lower extremity that failed outpatient treatment with Keflex. He did not meet sepsis criteria by the strictest definition. However, he did have bandemia and lactic acidosis. There was no radiographic evidence of any concerning findings such as necrotizing fasciitis, or an abscess. There is no mention made of compartment syndrome either. Additionally, the patient did report pain with ambulation. From the emergency department he was maintained on intravenous antibiotics until improvement was noted and physical therapy evaluated him. He was discharged after his blood cultures were negative with oral antibiotics.
Given that the patient presented after failure of adequate outpatient antibiotic treatments for 48 hours and with concerning findings such as bandemia and lactic acidosis, I find that this admission was medically necessary in order to treat him safely and effectively.