Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned in part. 


The patient has a past medical history significant for bladder cancer, tobacco use disorder, peripheral arterial disease, hyperlipidemia, and benign prostatic hyperplasia (BPH) who presented to the emergency department with complaints of right lower extremity redness and swelling which had been going on for five days. The patient reported a subjective fever and chills. Reportedly, he was working in an abandoned building for several days before his symptoms started. He went to the urgent care clinic, where he was given a prescription for oral antibiotics. The patient stated that he had no improvement in his symptoms despite taking the antibiotics. His review of systems was negative for everything except for the symptoms listed above. 

When the patient was seen by the admitting physician, he was afebrile. The pulse rate was 69 beats per minute (bpm), respiratory rate 18 breaths per minute, blood pressure 138/83, oxygen saturation 97% on room air. 
The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits. The patient had a heart regular rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. 
There was 2 plus (+) right lower extremity edema and erythema from the right ankle to the right mid-thigh. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 7.3, hemoglobin 13.3, hematocrit 38.5, and platelets 301. The sodium was 137, potassium 4.9, chloride 103, bicarbonate 25, blood urea nitrogen (BUN) 15.7, creatinine 0.7, and glucose 83.
The patient was admitted to the hospital with right leg cellulitis. He was started on intravenous antibiotics. 

On the next day after the day of admission, the patient was seen by an infectious disease specialist who diagnosed the patient was recurrent cellulitis of the right lower extremity as well as peripheral vascular disease, status post right lower extremity vascular bypass surgery. 
The infectious disease specialist recommended awaiting culture results and treating the patient empirically with antibiotics. In addition, the patient was seen by vascular surgery who suggested that there were no signs of infection around the graft site. There was no need for any surgical intervention. Treatment with intravenous antibiotics was recommended. 

At issue is the medical necessity of an inpatient stay. 

The inpatient stay was medically necessary in part. 

The patient presented to the hospital with lower extremity cellulitis that had clearly failed outpatient treatment. The patient had been treated with appropriate oral antibiotics for 48 hours without significant improvement in his symptoms. The swelling and redness in the lower extremity persisted. Therefore, admission to the hospital for administration of intravenous antibiotics was necessary due to the failure of outpatient treatment in the patient with a previous history of peripheral arterial disease. Failure of outpatient treatment with appropriate antibiotics is one of the criteria listed in the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 25th Edition criteria for Cellulitis. 

In addition, this patient had a history of peripheral arterial disease, which would be a significant risk factor for adverse outcomes. 
However, although the admission at the acute inpatient level of care was appropriate at the beginning of the hospitalization, the entire length of the hospitalization was not medically necessary/justified. 
By the fourth day, the patient remained afebrile and hemodynamically stable. According to the progress note, he was out of bed in a chair, with no complaints of leg pain. His white blood cell count was normal and the blood cultures showed no growth. According to the progress note, the right lower extremity cellulitis improved. 
There was no evidence that the patient required frequent administration of parenteral pain medications. There were no records of limb-threatening infection, bacteremia, necrotizing soft tissue infection. The patient was evaluated by the surgical service, they did not recommend any surgical intervention. There was no need for surgical wound care. 
Considering the overall stability of the patient's condition, he exhausted the benefits of continuation of care in the hospital and could have been safely transitioned to a lower level of care, perhaps with the recommendation to continue intravenous antibiotics.
Therefore, continuation of an inpatient hospital stay is medically necessary in part; 4 days were medically necessary; the additional stay was not.