Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral foot ulcers
Treatment: Inpatient admission
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male who initially presented to the emergency department with concerns for non-healing bilateral foot ulcers of a one month duration. The patient has a history of diabetes mellitus. His initial vital signs revealed a temperature of 98.3 Fahrenheit, heart rate (HR) of 64, blood pressure (BP) of 149/79, respiratory rate (RR) of 18 and his peripheral capillary oxygen saturation (SpO2) was 98 percent (%) on room air. The patient's initial examination documented the patient as alert and oriented with swelling between his 2nd and 3rd toes. His initial laboratory testing revealed a white blood cell count (WBC) of 8.0, hemoglobin (Hgb) of 14.6, platelets (Plt) 266, blood urea nitrogen (BUN) 12, creatinine 1.0 and his glucose was 323. His laboratory studies also revealed that his erythrocyte sedimentation rate (ESR) was 8, C-reactive protein (CRP) was less than (<) 0.4 and his creatine kinase (CK) was 59. An x-ray of his foot did not reveal any acute findings. The patient was placed in the hospital with an impression of non-healing diabetic foot ulcers and hyperglycemia. The patient's treatment plan included empiric antibiotics, subcutaneous Insulin and consultations. The patient remained afebrile and hemodynamically stable. His WBC count was 8.9, glucose 88, and his hemoglobin A1c (HbA1c) was 8.1%. The attending physician documented no signs of infection. There was a plan to discharge the patient.

Infectious disease was consulted and noted the patient had diabetic foot ulcers involving the 2nd and 3rd digit interdigital space. Recommendations were made to continue empiric antibiotics and obtain a magnetic resonance imaging (MRI) of the foot. If the MRI was negative, the patient would then transition to an oral regimen. There was no change in his clinical condition or plan. Topical wound care provided. The MRI did not reveal osteomyelitis and oral antibiotics were recommended and the following day the patient was discharged.

As per Ramakrishnan et al., inpatient treatment is necessary for patients who have an uncontrolled infection despite adequate outpatient antimicrobial therapy or if they cannot tolerate oral antibiotics. Hospitalization is also indicated for patients who initially present with severe or complicated infections, unstable comorbid illnesses, or signs of systemic sepsis. Broad-spectrum antibiotics with proven effectiveness against gram-positive and gram-negative organisms and anaerobes should be used until pathogen-specific sensitivities are available. Once this is established, coverage can then be narrowed. Intravenous antibiotics should be continued until the clinical picture improves, the patient can tolerate oral intake, and drainage or debridement is completed.[1]
The patient had a history of diabetes mellitus and non-healing foot wounds who presented due to concerns of non-healing foot wounds. On the initial evaluation the patient was afebrile, hemodynamically stable and without evidence of a systemic inflammation. The radiograph of the foot did not reveal acute pathology. The patient's HbA1c was 8.1%. The patient's serum glucose was controlled and the attending physician documented no signs of infection with a plan for discharge. 

The patient did not have a failure of outpatient therapy, he did not have an HbA1c that was greater than (>) 10%, a limb-threatening infection, bacteremia, persistent altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, the inability to maintain oral hydration, or severe pain requiring inpatient management. The patient did not require an associated surgical procedure (i.e., abscess drainage, debridement) or any other condition or treatment that would necessitate an inpatient admission.[2]