Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

The patient is a child with Down Syndrome and hypothyroidism. The patient presented to the hospital with left leg pain, redness, and swelling. The temperature was 102 (degrees) Fahrenheit (F), and the patient vomited three times. The review of systems was otherwise negative. There was no anuria or decreased appetite. 
 
The patient had a fall just prior and scratched both their knees, and the next day, the family ate duck at a restaurant for the first time. The patient came home with a stomachache and immediately vomited. The patient's mother noticed a rash on the patient's left leg while changing their clothes. The rash was painful enough to keep the patient from walking. The patient vomited twice more and only could tolerate a small amount of fluids.

On presentation, the patient's vital signs were blood pressure (BP) 90/61, heart rate (HR) 144, and temperature 102.9 F orally. The temperature came down to normal within about two hours while in the emergency room (ER). Upon examination, the patient was alert and nontoxic. The patient had scabbed abrasions on both knees. There was erythema (indicated on the diagram) from mid-thigh to the ankle, with a normal capillary refill. The patient had a full range of motion and could move the left leg independently despite the left calf muscles being tender to touch. No drainage or fluctuance was noted. Other systems exams were normal. Later in the chart, the rash is described as looking more like erysipelas being fairly demarcated, and Infectious Diseases is said to continue the same regimen. The rash improved rapidly over the next day in the hospital.
 
Labs revealed mild hyponatremia 131, no lab evidence of dehydration, C-reactive protein (CRP) slightly elevated at 8.9, and leukocytosis with white blood cell count (WBC) 25000 with predominance of neutrophils 89% (percent) with 2% bands.  

A decision was made to admit the patient and administer intravenous (IV) antibiotics. It is stated in the Admission Certification Note that the purpose of admission was to evaluate and treat the diagnosis of cellulitis and systemic inflammatory response syndrome (SIRS), requiring IV antibiotics and close monitoring. However, the record lacks any explicit medical decision-making to support this plan of management. 

Specifically concerning erysipelas, "most cases of erysipelas can be managed with oral antibiotics in the outpatient setting" (Spelman et al.). Even if the patient had concomitant cellulitis, there was no sign of hemodynamic instability, progression, or abnormal local signs suggesting a deep tissue infection. Outpatient therapy with oral antibiotics is indicated for healthy persons with non-purulent cellulitis if they have no evidence of systemic inflammatory response syndrome (SIRS). Criteria for admission to the hospital for administration of parenteral antibiotics and monitoring include red flag conditions, which entail the risk of progression of infection, including systemic signs of toxicity, especially hypotension or sustained tachycardia, rapid progression of erythema over hours, with pain, raising suspicion of necrotizing fasciitis, an immunocompromising condition, facial involvement, pyomyositis, joint involvement, compartment syndrome or an inability to tolerate or absorb oral antibiotics (Stevens et al.).

The patient did not have any of these red flag signs. The infection was not progressive or severe. The patient did not have severe swelling and pain. The exam did not reveal a spreading or worsening infection.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for the inpatient admission is not substantiated.