Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis 
Treatment: Inpatient emergency admission

The health plan denied Inpatient emergency admission.
The determination is Upheld.

The patient is a male who initially presented to the emergency department following a fall with head impact. His pertinent past medical history included atrial fibrillation, left lower leg cellulitis, hypertension, and alcohol abuse. His initial vital signs revealed a temperature of 97.7 degrees Fahrenheit, a heart rate (HR) of 72 beats per minute (bpm), blood pressure (BP) of 122/90 millimeters of mercury (mmHg), and a respiratory rate (RR) of 18 breaths per minute. The initial examination documented a scalp laceration and bilateral lower extremity edema with multiple open wounds in the left leg. His electrocardiogram (EKG) was unremarkable. His scalp laceration was repaired, and empiric vancomycin was administered. He was admitted to the hospital for cellulitis and fall with left scalp laceration. The treatment plan included empiric vancomycin and supportive care. The patient requested to leave against medical advice and was given a prescription for oral doxycycline.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient level of care was not medically necessary for this patient. Based on the clinical documentation provided, evidence-based literature, and standards of care, the acute inpatient level of care was not indicated as medically necessary for the entire admission.
Ramakrishnan et al. note that inpatient treatment is necessary for patients who have uncontrolled infections despite adequate outpatient antimicrobial therapy or those who cannot tolerate oral antibiotics. Hospitalization is also indicated for patients who initially present with severe or complicated infections, unstable comorbid illnesses, or signs of systemic sepsis. Broad-spectrum antibiotics with proven effectiveness against gram-positive and gram-negative organisms and anaerobes should be used until pathogen-specific sensitivities are available; coverage can then be narrowed. Intravenous antibiotics should be continued until the clinical picture improves, the patient can tolerate oral intake, and drainage or debridement is completed. [1]
The patient presented to the hospital following a fall with scalp laceration. The initial evaluation found the patient to be afebrile and hemodynamically stable with bilateral lower extremity erythema and left leg purulent drainage concerning for cellulitis. There was no documentation of failed outpatient treatment and no signs of sepsis. Treatment included supportive care and observing the effects of empiric antibiotic therapy. No other acute issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have a failure of outpatient therapy, a glycated hemoglobin greater than 10 percent (%), a limb-threatening infection, bacteremia, persistent altered mental status, hemodynamic instability, a suspected necrotizing soft tissue infection, inability to maintain oral hydration, or severe pain requiring inpatient management. In addition, the patient did not require an associated surgical procedure not amenable to outpatient, emergency department, or observation care or any other condition, treatment, or monitoring requiring inpatient admission. [2]