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 female who presented to the hospital with right more than the left lower extremity swelling and redness. She also had pain of the right lower extremity. A small superficial wound was present on the right leg in the anterolateral area. It was dry but some purulent discharge was present. The patient did not have any fever. There was no leukocytosis. Her past medical history was significant for chronic venous insufficiency. She was also obese and had hypertension. 
There were no signs of necrotizing fasciitis noted. The patient did not have a prosthesis in the right lower extremity or wound with probe to bone. She did not have kidney or liver acute dysfunction. Her blood pressure was normal and there was no sustained tachycardia or tachypnea. Mental status was normal. The patient was administered one dose of antibiotic and was hospitalized. Wound care consult recommended no operative intervention. Elevation along with an intravenous antibiotic was recommended. Blood cultures were obtained, and a methicillin resistant staphylococcus aureus (MRSA) swab was obtained as well. Methicillin resistant staphylococcus aureus (MRSA) swab was negative. The patient was continued on Ancef therapy and improved over the next two to three days. She was discharged with an oral antibiotic treatment.

The proposed inpatient hospitalization was not medically necessary.

Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness that is acute. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk is based on an assessment of medical factors in the context of known and generally accepted medical knowledge prevalent at the time of determination. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the outpatient setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition. In this patient's condition, vital signs were normal, routine labs including white blood cell count were normal. There was no organ dysfunction present such as kidney or liver dysfunction. Mental status was normal. The patient did not have necrotizing fasciitis or other signs of deeper infection in the right to extremity. No surgical intervention was required. There is no 
compromise of vascular or neurological function of the right lower extremity. The patient did not have any severe nausea or vomiting. Routine antibiotic treatment was indicated. However, she did not require intravenous continuous or multiple doses of analgesics. Pain was controllable with oral treatment. Oral antibiotics would have been successful in managing this patient's cellulitis. Intravenous treatment was not required because the patient did not have persistent nausea or vomiting. Oral intake was normal. There were not intractable symptoms. There was no intractable or unstable comorbid condition.