Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis of the leg after insect bite
Treatment: Inpatient Admission
The insurer denied Inpatient Admission.
The denial is upheld.

The patient is an adult male with known history of HIV (human immunodeficiency virus. His labs from last year showed CD4 (cluster of differentiation) 51. The patient is on Biktarvy for HIV (human immunodeficiency virus). He presented complaining of 
severe pain involving mid right lower leg. He stated that he had an insect bite at his right leg approximately one week prior, which subsequently became infected. He was seen in the ED (emergency department) the day before presentation for pain and swelling at the site of the bite. He was given one dose of antibiotic and some pain medication and DC (discharged) home with antibiotic clindamycin to continue treatment as outpatient. He did not get the medication, because he did not have the co-pay money. The patient came back to the ED (emergency department) on the day of presentation due to pain, 
swelling and redness of the same area. The patient did not have fever, chills, nausea, vomiting, headache, or dizziness. Examination showed erythema RLE (right lower extremity), mid aspect, central open ulcer with bloody, purulent discharge, peripheral redness, painful to touch. The patient's vitals showed the following: Temperature 36.7 degrees Celsius (98.1 degrees Fahrenheit), P (pulse) 99, R (respiration rate) 20, BP (blood pressure) 140/86, and SpO2 (pulse oximetry) 97 % (percent) on room air. Labs showed WBC (white blood count) 3.6 and Platelet 292. X-ray of the patient's right leg revealed normal right tibia and fibula. There was no radiographic evidence for osteomyelitis. Venous Doppler was negative for deep venous thrombosis. The patient was started on treatment with IV (intravenous) Zosyn and Vancomycin. He was given morphine for pain control and also started on IV (intravenous) fluids. Infectious disease consult was requested. The patient continued to improve and was discharged on oral antibiotics.

The Inpatient Admission was not medically necessary.

The patient presented for cellulitis of the leg after insect bite. The patient was afebrile on presentation, WBC (white blood count) 3.6, and results of evaluation / lab results did not show presence of sepsis / systemic infection. Vitals were stable without notable hypotension or tachycardia, and the patient's mental status was maintained. The patient was able to continue taking oral intake on presentation. X-ray was negative for osteomyelitis, and venous Doppler was negative for DVT (deep venous thrombosis). The patient did not evidence sepsis / systemic infection on presentation and did not need inpatient admission for management. The patient could have been safely and effectively managed at a lower level of care without inpatient admission. 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 for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. 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. The patient was not in acute distress, and in view of these facts of the patient's clinical status, ongoing risk of deterioration was low since diagnosis had been established and the patient was responding appropriately to the treatment.
The inpatient care was not medically necessary.