Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg swelling and pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an elderly male with a past medical history of hypertension, diabetes, insomnia, and chronic lower extremity pressure ulcer. The patient has had history of multiple emergency room visits for lower extremity cellulitis in the past. The patient presented to the hospital with reports of leg swelling and pain. The patient reported chronic ulcers to the leg with some worsening. There was no history of fever. The patient's vitals in the emergency room were pulse 103, blood pressure 131/59, respiratory rate 20, temperature 98.5 and oxygen saturation 100%. Examination showed bilateral lower extremity swelling, with multiple healing ulcerations and legs weeping. Labs results showed white blood cells 12.8, hemoglobin 10.3, hematocrit 32.2, and normal chemistry. The patient's x-ray of both the tibia and the fibula did not show fracture or any acute findings but showed soft tissue swelling over both ankles and lower calves, along with likely sites of superficial ulceration. 
The patient was started on treatment with intravenous vancomycin, intravenous Toradol, and intravenous morphine, and the patient was subsequently admitted for further evaluation and treatment. The patient was evaluated by Infectious Disease consult during admission and the advice was to discontinue Vancomycin and start Ancef. The patient was also continued on pain medications. The patient also received wound care for the chronic leg ulcers, and he was also evaluated by physical therapy - they advised home physical therapy with home services. The patient was also evaluated by podiatry. The patient continued to be hemodynamically stable and without any new symptoms/findings and was discharged.

The medical need for inpatient hospital admission was not established.

The patient was afebrile and had stable vital signs. 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. His 
physical exam for this duration did not show any new exam findings that would necessitate further workup in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for workup or change in management plan in an inpatient setting. The patient was hemodynamically stable and afebrile. For the above duration, the patient had stable vital signs and routine labs remained at baseline. The patient's temperature and other vital signs were not representative of sepsis during this time. General and systemic examinations were normal or at baseline. The patient was able to eat food, drink fluids and take oral medications. Although the patient had pain, it was not intractable, and was noted to be amenable to appropriate oral treatment. The patient was not in acute distress and in view of these facts of the patient's clinical status, the illness was in the post-acute phase and ongoing risk of deterioration was low since diagnosis had been established and the patient was responding appropriately to the treatment. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness in the post-acute phase 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. In view of these findings and generally in accordance with standard medical care, therefore, the inpatient level of care was not medically necessary.