Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection of leg wounds
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history of intravenous drug abuse, smoking, asthma, depression/anxiety, and chronic venous insufficiency who presented to the hospital with a one-month history of lower extremity edema, erythema, pain, discharge, and areas of "dead tissue." The patient had been self-treating the wounds by wrapping his legs and changing dressings daily, noting white to orange drainage at times. No fevers were reported. It was revealed that the patient was currently using heroin and had injected it into his legs a few hours prior to the presentation. Previous medical records indicated that the patient had been seen in the emergency department with a similar complaint and had been admitted but left against medical advice after a prolonged stay.
The skin examination revealed warm and dry skin, significant bilateral lower extremity edema consistent with chronic venous stasis, multiple open wounds with areas of necrotic tissue, no active discharge, small area of active bleeding on the right lower extremity, surrounding erythema, and no warmth. 

An x-ray of the tibia and fibula bilaterally revealed a soft tissue defect along the anterior aspect of the bilateral lower legs, right greater than left, with subcutaneous emphysema consistent with the patient's known bilateral lower extremity cellulitis and ulcer. Findings progressed compared to a prior radiograph. There were no findings to suggest osteomyelitis, no fracture or dislocation. In the hospital, the patient was seen by the infectious disease specialist who recommended discontinuation of intravenous antibiotics and starting Bactrim for 7 days. The patient decided to sign out of against medical advice (AMA) and leave the hospital. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
In general, admission at the acute inpatient level of care is indicated for patients with cellulitis/soft tissue infection 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 the treatment of cellulitis.
A lower level of care was reasonable to ensure a response to antibiotics and in order to decide about antibiotic treatment after discharge. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Overall, this patient presented in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.