Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with past medical history significant for intravenous drug use, polysubstance use disorder (cocaine and heroin), methadone dependence, hypertension, Hepatitis C, post-traumatic stress disorder and anxiety. The patient presented to emergency department with complaints of acute worsening left arm pain and swelling after intravenous drug use. The patient started having symptoms of left arm pain and swelling for about one week before presentation. The patient reported receiving a dose of cocaine and one day later developed a bump at the injection site at the posterior aspect of the left forearm. The patient also developed symptoms of malaise, nausea, anorexia, headache and dizziness. Over the next few days, the pain and swelling worsened and the patient presented to the emergency department for evaluation. Evaluation in the emergency room showed the following vital signs: temperature (T) 36.4, blood pressure (BP) 126/87, pulse (P) 102, respirations (R) 18, and oxygen saturation (SpO2) 97 percent. The patient was noted to have left forearm swelling, induration, erythema, a four-centimeter round area of erythema, and limited range of movement of left elbow. Bedside ultrasound showed cobble stoning and evidence of cellulitis. The patient's labs showed an international normalized ratio (INR) of 1.28. His computed tomography (CT) scan of the left forearm confirmed cellulitis.
The patient was treated with intravenous fluids and intravenous antibiotics, including vancomycin, during his hospital stay. He improved and was discharged.

The inpatient admission was not medically necessary.

This patient presented to the hospital emergency room due to clinical presentation of cellulitis after intravenous drug use. The patient was however afebrile on presentation and had stable blood pressure. The patient did not have any systemic manifestations to indicate systemic sepsis or septic shock that would necessitate admission to the hospital. The patient's mental status was also stable. The ultrasound and computed tomography scan did not show abscesses that would require drainage in a inpatient setting. The patient needed antibiotic treatment and he was started on intravenous antibiotics. However, the management could have been safely and effectively achieved at a lower level of care without need for admission to the hospital. 
Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. For the duration of the hospital stay, 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. The patient was tolerating oral intake and was clinically stable. Care rendered during this time was of low intensity, routine nursing and physician monitoring. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary. In view of these findings and generally in accordance with Milliman Care Guidelines (MCG) therefore, the ongoing inpatient level of care for the above duration was not medically necessary.