Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient Hospital

The patient is a male with a past medical history significant for asthma who presented to the emergency department according to the recommendation of his podiatrist for evaluation of left heel abscess.
Reportedly, approximately 2 weeks before the day of admission, the patient noticed a "boil" on the surface of his left heel. This lesion was associated with pulsating pain, which the patient reported as 8/10 in intensity. The "boil" increased in size. Because of the pain, the patient was unable to put on his shoe for one week. The patient noticed that the lesion started to drain yellow discharge. He went to see a podiatrist one day before the day of admission and was referred to the emergency department.
At the time of the initial evaluation, the patient admitted to occasional chills and night sweats. He denied fever, cough, nausea, vomiting, abdominal pain, recent travel, or sick contacts.
Reportedly, while visiting the podiatrist in the office, the patient was referred to an x-ray and magnetic resonance imaging (MRI) of the foot. The MRI demonstrated mild Achilles non-insertional tendinitis and peritendinitis without tear and mild retrocalcaneal bursitis.
At the time of the initial evaluation patient's temperature was 97.9F, heart rate 69, respiratory rate 15, and blood pressure 119/84, with an oxygen saturation 99% on room air.
The patient appeared comfortable, in no acute distress. Lungs were clear to auscultation, the cardiovascular exam was unremarkable.
The patient had an open left heel wound resembling abscess, which was approximately 1x1 centimeter (cm) with granulation tissue. There was no active bleeding or discharge. The patient experienced pain with flexion and dorsiflexion. The rest of the exam was unremarkable.
In the hospital, the patient was seen by a podiatrist who examined the patient and found a wound that was 1.0 by 1.5 cm. It was tender to palpation. The wound base was completely granular with no surrounding hyperkeratosis, erythema, edema, purulence, malodor, fluctuance, or other clinical signs of infection.
The podiatrist performed mechanical debridement and irrigated with a copious amount of Saline and Betadine. A culture of the left heel wound was obtained and brought to the lab. The wound was dressed with dressing and an ABD pad.
At the time of admission, laboratory evaluation was performed and demonstrated the patient's white blood cell count was 6.5, hemoglobin 13.4, hematocrit 40.5, platelets 198. Sodium was 136, potassium 4.5, chloride 99, bicarbonate 29, blood urea nitrogen (BUN) 9, creatinine 1.1, glucose 99. Erythrocyte sedimentation rate (ESR) 9. Liver function tests were within normal limits.
While in the hospital, the patient underwent a duplex ultrasound of the right lower extremity, which demonstrated no evidence of deep vein thrombosis (DVT).
During the hospital stay the patient was not treated with intravenous antibiotics. Subsequently, when the blood cultures came back negative, the patient was transitioned to an oral antibiotic and was discharged from the hospital.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient at the acute inpatient level of care.
This patient presented to the hospital according to the recommendation of his podiatrist, with abscess of the heel, which was drained prior to the patient coming to the hospital. At the time of the initial evaluation, this patient had a wound on the surface of the left heel, which had no signs of bleeding or discharge. Furthermore, when the patient was evaluated by a podiatrist in the hospital, it was indicated that the patient had no evidence of surrounding hyperkeratosis, erythema, edema, or purulence. There was no evidence of fluctuance in the area. The patient was afebrile, had normal white blood cell count, and normal erythrocyte sedimentation rate. Taking into consideration all these circumstances, the presence of a serious infection in the wound that would require treatment with intravenous antibiotics in the hospital was questionable at the time of the admission.

If the infection in the area was still suspected by the admitting physician, it was reasonable to admit the patient for a short period of monitoring and treatment. At the same time, the review of the patient's data revealed that neither the severity of the patient's condition nor the complexity of the services provided justified admission at the inpatient level of care. There was not strong evidence of local infection in the wound, osteomyelitis, or any systemic response to possible infection. 
There was no evidence that the patient had surrounding cellulitis. There was no mention that the patient had persistent nausea and vomiting and was unable to tolerate oral pain medications.

There was no mention that the patient was immunocompromised or had a peripheral arterial disease. There was no mention that the patient had any other medical conditions necessitating admission at the acute inpatient level of care.
 
Taking into consideration all these facts, the hospital stay was not medically necessary at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.