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 whose inpatient hospital admission: is under review. He presented to the hospital with swelling, redness and pain of the lower extremities, left more than right. 

On examination, the patient was afebrile and hemodynamically stable. Both legs were darkened and indurated with evidence of chronic venous insufficiency. Pulses in both feet were palpable and there was no compartment syndrome, with normal ability to flex, extend ankle and toes. There was a small blister noted on the left medial ankle with some oozing. No necrosis or crepitus is described and no finding of violaceous discoloration or purpura is noted. The right leg had a chronic ulcer on the lateral ankle region and a small ulcer on the medial aspect of the ankle without evidence of purulence or palpable bone described. Again, no findings of compartment syndrome were noted and no findings suggestive of necrotizing fasciitis were described in the provided records. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were highly elevated but white cell count was near normal. Chemistry panel was normal. X-ray of the right leg demonstrated possible osteomyelitis and subsequent magnetic resonance image (MRI) demonstrated no osteomyelitis. Infectious Diseases and Podiatry consultation were sought and broad spectrum antibiotics were administered parenterally. The patient was discharged three days later.

The proposed inpatient hospital admission was not medically necessary.

Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness that is acute. In this patient's case, there was a lack of findings that would suggest arterial insufficiency and the patient had chronic venous insufficiency without findings such as Homan's sign or calf pain and swelling which would suggest deep venous acute thrombosis. Duplex venous ultrasound showed no deep venous thrombosis. There was also no clinical evidence of osteomyelitis since there was no ulcer overlying the area of concern on X-ray for bony infection. There was no description of probe to bone or ulcer going to bone. The patient did not have findings of necrotizing fasciitis such as crepitus, pain out of proportion to signs, violaceous discoloration, sepsis, bulla, purpura or gas in tissues on X-ray. There was no finding of compartment syndrome and pulses in both dorsalis pedis arteries were palpable. The patient did not have sepsis or acute organ dysfunction accompanied by fever, moderate to high leukocytosis, or alteration in chemistries. Mental status was normal, the patient was non-toxic and did not have any acute distress on examination. 

There was no need for complex wound care, and no presence of hardware in the involved limb. The patient did not have bacteremia, liver disease, renal disease, active malignancy, immunosuppression or severely uncontrolled diabetes mellitus or infection below the ankle, as would be the case with diabetic foot infection. There were no intractable symptoms, inability to take medications orally, gastrointestinal (GI) intolerance or symptoms and no psychiatric comorbidity.

Given these facts, the patient's condition was of mild nature, and sub-acute, not requiring inpatient hospitalization. There was no particular need for parenteral antibiotics. Therefore, inpatient hospital care was not medically necessary.