Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Rash
Treatment: Inpatient hospital admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is upheld.

This case involves a woman with hypertension who was admitted to the hospital with bilateral foot pain for three months. She also is experiencing itching to the bottom of her feet. Antipruritic creams have not helped, and the symptoms affect her ambulation ability. On exam, the patient had yellow skin thickening to the bilateral soles, cracking, and small areas of ulceration. She had dry, scaly skin on the bilateral palms and macular rash throughout the bilateral upper and lower extremities with excoriations. Vital signs appeared stable.
Laboratory studies included a normal complete blood count (CBC), the chemistry panel was unremarkable, and liver function tests (LFTs) did not show any abnormalities. An X-ray of the foot showed no fracture or dislocation.
The patient was admitted to the hospital with a dermatology and podiatry consultations. The podiatrist assessed the patient and recommended weight bearing as tolerated, ammonium lactate twice a day, and no further interventions. The dermatologist suspected Palmar plantar psoriasis versus acral electrolytic erythema with lichenoid features. They recommended Clobetasol ointment twice a day. They also recommended testing for viral hepatitis, gonorrhea, chlamydia, and syphilis. The medical team notes the patient has a history of hepatitis B and is chronically on Tenofovir, which could be responsible for the rash. In addition, the patient has rheumatoid arthritis and takes Hydroxychloroquine, which can also be responsible for the rash.
The patient remained in the hospital and was reassessed the next day, showing stable vital signs. The exam was relatively unchanged. Dermatology has recommended outpatient follow-up for possible biopsy if she does not respond to the steroids. The patient remained in the hospital for two additional days before being discharged home.
The question is whether an inpatient hospital admission was medically necessary for this presentation.

I fully uphold the health plan's determination of medical necessity.

No. An inpatient admission was not indicated. This was an outpatient work-up that was completed in the hospital setting.
The patient's chronic rash is followed by podiatry and dermatology in the outpatient setting. Evaluation in the emergency department (ED) failed to reveal any major abnormalities that warrant further hospitalization. The recommendations from podiatry and dermatology were for further outpatient work-up and obtaining labs to rule out infectious and autoimmune etiologies of the patient's rash. None of this is life-threatening or emergent. These work-ups are completed in the outpatient setting and do not require inpatient admission. The patient was hemodynamically stable and was receiving treatment with topical corticosteroid creams and emollients. The documentation fails to demonstrate that the rash is related to cellulitis and the need for intravenous (IV) antibiotics. There is absolutely no reason to consider this a life-threatening state that would indicate the need for an inpatient admission.