Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders/Cellulitis
Treatment: Inpatient Admission
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is overturned.

The patient is a female who presented to the emergency department with complaints of redness and swelling in the right hand which had been going on for 12 days. She was seen in the emergency department for the same problem and was recommended admission for cellulitis but left against medical advice (AMA). Reportedly, the patient previously had an intravenous (IV) placed in the same area when she was seen in a different emergency department for evaluation of syncope, but also left the emergency department AMA. The patient complained of throbbing dull pain in the right wrist/hand. She stated that the pain worsened in the area of the right thumb and wrist.
The review of systems was negative for fever, nausea, vomiting, diarrhea, shortness of breath, chest pain, abdominal pain, or any other symptoms. At the time of the initial evaluation, she was afebrile. Her heart rate was 71 beats per minute (bpm), with a respiratory rate of 18 breaths/min, a blood pressure of 101/66 millimeters of mercury (mmHg), and an oxygen saturation was normal.
The patient was in no acute distress. An X-ray of the right wrist showed no evidence of fracture or dislocation. An X-ray of the right hand was also unremarkable.
The patient was admitted to the hospital with a diagnosis of cellulitis of the right hand. It was mentioned that the patient finished a course of Cephalexin 4 days prior to admission. The admitting physician stated that the patient failed outpatient treatment with antibiotics, therefore, the patient required admission for the administration of intravenous antibiotics.
In the hospital, the patient was seen by an infectious disease specialist who recommended treatment with intravenous Ancef, obtaining a magnetic resonance imaging (MRI) of the right hand, and consulting with a hand surgery specialist. It was also mentioned that the patient had a right upper extremity venous duplex ultrasound, which was negative for deep venous thrombosis of the right upper extremity.
The MRI of the right hand was performed and demonstrated subcutaneous edema, and minimal tendon sheath fluid accumulation involving the extensor carpi radialis brevis tendon which could be a manifestation of tenosynovitis. The hand surgery specialist evaluated the patient and recommended treatment with intravenous antibiotics, hand elevation, and warm compresses. At the end of the hospitalization, the patient was transitioned to the oral antibiotic Keflex, and was  discharged home.
At issue is the medical necessity for the inpatient stay.

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

Admission at the acute inpatient level of care is indicated for patients with cellulitis who failed outpatient treatment. In this clinical case, the patient clearly failed outpatient treatment since she finished a course of treatment with the oral antibiotic Keflex four days before her presentation without significant improvement in her symptoms.
Furthermore, the patient clearly demonstrated signs of medical noncompliance by signing out against medical advice on several occasions. That would justify admission for the administration of intravenous antibiotics and close monitoring of clinical response.
Considering the patient's previous history of drug abuse, the administration of intravenous antibiotics should have been performed in the hospital. The admission at the acute inpatient level of care was completely justified, considering the clinical circumstances including the failure of outpatient treatment with oral antibiotics, medical noncompliance, and a history of drug abuse.