Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Foot Cellulitis
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male with no past medical history who presented to ED (emergency department) with right (R) foot redness and swelling. He reported dropping a pair of scissors on his foot two days prior to presentation and had a small cut on dorsum of foot. The area began to swell, with redness and pain, and he reported fevers and difficulty ambulating.
In the ED (emergency department) his temperature was 101.7 (degrees Fahrenheit) to a maximum temperature of 102.8 (degrees Fahrenheit), pulse 116, blood pressure (BP) 120/70, respiratory rate (RR) 18 and his room air (RA) saturation was 96 percent (%). He was noted as "not in acute distress", no respiratory distress, normal mood and affect, alert and oriented to person, place and time. Noted two punctures on dorsum R (right) foot, no bleeding, pus, fluctuance. The R (right) foot was erythematous and warm to touch.
His laboratory studies revealed lactate 1.19, international normalized ratio (INR) 1.5, creatinine 1.1 and he had normal liver functions. His white blood cell count (WBC) was 34.4, platelets (Plt) 217, hemoglobin and hematocrit (H/H) 13.1/40.2 and his C-reactive protein (CRP) was 18.8. The x-rays of the R (right) foot showed soft tissue swelling, no gas, no fracture. The electrocardiogram (EKG) showed normal sinus rhythm (NSR). Blood cultures were drawn, patient started on empiric Zosyn and Vancomycin, and he was admitted with diagnosis of sepsis secondary to R (right) foot cellulitis. He was given Tylenol in the ED (emergency department) and defervesced. His temperature was 99.7 (degrees Fahrenheit). Infectious disease (ID) and Podiatry were consulted. Infectious disease advised changing Zosyn to Cefepime and continue Vancomycin. Podiatry aspirated fluid and no purulence noted. Blood cultures resulted in no growth. He had magnetic resonance imaging (MRI) of the R (right) foot that showed findings of cellulitis dorsum of foot but did not show any evidence of osteomyelitis. A chest x-ray (CXR) on admission was clear. The human immunodeficiency virus (HIV) test was negative.
The WBC (white blood count) was 26.7 and his temperature was 99.1 (degrees Fahrenheit) (37.3 degrees Celsius). He remained hemodynamically stable throughout. He was noted to be clinically improving, with improving cellulitis but still tender. The WBC (white blood count) then was 18.4 and his CRP (C-reactive protein) was 14.6. He was discharged on oral Augmentin and Doxycycline, per infectious disease (ID).

The Inpatient level of care was not medically necessary for this patient. This patient has no comorbid conditions and he is not immunocompromised. He presented with high fever, tachycardia, leukocytosis, with obvious source of infection - R (right) foot cellulitis after sustaining puncture wounds two days prior when he dropped a pair of scissors on his foot. He was hemodynamically stable from presentation and throughout admission. He did not have findings of necrotizing soft tissue infection or necrotizing cellulitis or fasciitis. His x-ray and MRI (magnetic resonance imaging) showed soft tissue swelling but no gas, and he had no abscess collection. Aspiration of the foot by podiatry yielded no purulent fluid. His temperatures and WBC (white blood count) steadily down trended on broad spectrum antibiotics. He was not bacteremia and his blood cultures were negative. He had cellulitis of the foot. He did not have an infection overlying a prosthesis or prosthetic material, he did not have infection around the eye, he did not have uncontrolled pain, he did not require surgical intervention, there is no indication that he was unable to tolerate an oral intake. There is no documentation that the patient ever had altered mental status. He did not fail a trial of outpatient therapy and there was no indication of failure to respond to provided treatment or any expectation that he would fail to respond. 

The health plan's determination of medical necessity is upheld in whole.