Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection (left heel and leg)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male with past medical history significant for diabetes mellitus, hypertension, hyperlipidemia, chronic kidney disease, deep venous thrombosis, diabetic neuropathy, left lower extremity angiogram and stenting, and ruptured Achilles tendon to left heel. The patient had been hospitalized in the recent past for left heel wound concerning for osteomyelitis. The patient presented to the emergency department with symptoms of worsening pain to the left lower extremity over the last three days. The patient also reported erythema and swelling to the left lower extremity. The patient's vitals in the emergency department were temperature 37 C (Celsius), blood pressure 137/89, pulse 87, respiratory rate 18, and pulse oximetry 98% [percent] (room air). On examination, the patient was noted to have tenderness and swelling to the left lower extremity. The patient also had pedal edema on the left side but did not have open wound. Lab results showed white blood cell count 9k (thousand), blood urea nitrogen (BUN) 29, creatinine 1.6, C-reactive protein (CRP) 114, glucose 171, and erythrocyte sedimentation rate (ESR) 81. Electrocardiogram (EKG) showed normal sinus rhythm at 81/minutes with occasional premature ventricular complex. Chest X-ray was negative for active pulmonary disease. Deep vein thrombosis (DVT) was not found on venous Doppler of lower extremity. X-ray of left foot showed non-displaced transverse fracture of the proximal shaft of the fifth metatarsal; there was no evidence of dislocation/osteopenia/cortical thickening and periosteal reaction involving the proximal shafts of the third and fourth metatarsal. Acute osteomyelitis could not be excluded. The patient was given intravenous vancomycin and Zosyn and admitted for treatment of cellulitis. During hospital stay, the patient was evaluated by infectious disease, podiatry, and vascular consult and labs were monitored. Ankle-brachial index/pulse volume recording (ABI/PVR) was completed and showed evidence of mild to moderate arterial insufficiency in the left lower extremity. The patient was continued on intravenous antibiotics during hospital stay and continued to improve and was discharged.

The inpatient admission was not medically necessary.

The patient presented with signs/symptoms consistent with cellulitis; however, he was afebrile on presentation and had stable vital signs and stable mental status. The patient had not failed prior outpatient antibiotic therapy immediately prior to presentation (he was noncompliant to antibiotic therapy). Clinical presentation was not consistent with sepsis/severe sepsis, and inpatient hospital admission was not warranted for treatment.
 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. Physical exam 
for this duration did not show any new exam findings that would necessitate further workup in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for workup or change in management plan in an inpatient setting. 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 for the above dates. In view of these findings, therefore, the ongoing inpatient level of care for the above duration was not medically necessary.