Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient hospital admission.

The insurer denied: Inpatient hospital admission.  The denial is upheld.

The patient is an adult male with a past medical history of alcohol (ETOH) abuse, hypertension (HTN), methadone dependence, and panic attacks, who presented with progressively worsening left lower extremity pain and swelling for two weeks, which started when he injured his left big toe. The redness and swelling progressed up to his knee. He denied fevers, chills or any discharge from the wound. In the emergency department, the patient's blood pressure (BP) was 154/82 millimeters of mercury (mmHg), heart rate (HR) was 99, temp maximum of 39.4 Celsius (C), and pain score was 6. The patient received ceftriaxone one gram intravenously with morphine for pain. One set of cultures were obtained. The patient was subsequently admitted to medicine for management of his cellulitis. The patient's labs showed a white blood cell (WBC) count of 10.6, platelets of 150, normal lactic acid, and normal prothrombin time. The patient's x-ray of the left tibia fibula / left foot showed no radiographic evidence of active bone infection. The patient was seen by the Infectious Disease, and they recommended to cover with cefazolin and vancomycin for methicillin resistant staphylococcus aureus (MRSA) given his left fibula open reduction internal fixation (ORIF) plate and screws. His vancomycin dose was adjusted as per pharmacy recommendations. 

The patient's symptoms progressively improved on the floors. The leg was less swollen, tenderness was almost resolved. The preliminary report of lower extremity duplex was negative for deep vein thrombosis (DVT). The patient was medically cleared for discharge to home with home care. His antibiotics were switched to Bactrim and Keflex after discussion with Infectious Disease with a plan to continue for three days.

The proposed inpatient hospital admission was not medically necessary.

This patient presented with left leg cellulitis. X-ray and deep vein thrombosis (DVT) study were negative for infection / deep vein thrombosis / fracture. The patient was febrile on presentation but did not have any findings on clinical evaluation / lab results to indicate sepsis / septic shock that would require immediate admission to the hospital. The patient did not have notable comorbid conditions to indicate greater chance of progression to sepsis / septic shock. 

For the duration dates in question, this patient had stable vital signs other than fever on presentation. 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. During the above duration, the patient's diagnosis had been established clinically and was based on the results of the investigations. Care rendered during this time was of low intensity, routine nursing and physician monitoring. 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 admission and stay.