Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult male with past medical history of cellulitis, neuralgia. He presented to the ED (emergency department) for evaluation of left lower extremity pain and cellulitis. The patient stated that about one week prior, he sustained a small cut on his distal lower left shin from a rock outside. He stated that for the prior one week, he had been working outside and standing in water, as his parents' basement had flooded. He stated that over the prior few days, he had increasing pain, surrounding cellulitis that has been extending up the leg towards the knee. The patient stated that he went to urgent care and was instructed to come to the emergency department for further evaluation and treatment. The patient reported clear discharge around site of initial wound, was not currently on antibiotics, and was unsure of last tetanus vaccine. The patient was admitted to the hospital for IV (intravenous) antibiotics.

The Inpatient Hospital Admission was not medically necessary.

On presentation, the patient denied no other complaints denies fever, chills, chest pain, shortness of breath, headache, dizziness, numbness or tingling, falls, recent travel or known sick contacts.

The patient's vitals on evaluation in the emergency room showed the following: T (temperature) 98.5, BP (blood pressure) 214/132, P (pulse) 82, R (respiration) 20, Pulse oximetry - 99% (percent). The patient's significant lab abnormalities were WBC (white blood count) 12.7, lactate 1.02. Ultrasound of leg did not show deep venous thrombosis.

Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. 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 as based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. 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 alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition.

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. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. The patient was able to eat food, drink fluids and take oral medications. Although the patient had pain, it was not intractable, and noted to be amenable to appropriate oral treatment. Care rendered during this time was of low intensity, routine nursing and physician monitoring. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. The patient did not have any acute complications during this time. No high frequency, high complexity, or high-risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. In view of these findings and generally in accordance with MCG (Milliman Care Guidelines) guidelines therefore, the ongoing inpatient level of care for the above duration was not medically necessary.