Diagnosis: Infectious Disease (Panniculitis), Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient with a past medical history significant for hypertension, asthma, chronic infra-umbilical hernia, morbid obesity, and bipolar disorder presented to the emergency department (ED) with complaints of cough, shortness of breath, and abdominal pain. Vital signs on presentation included: Temperature 37.2 C, Blood Pressure 155/81, Pulse 90, Respiratory Rate 18, oxygen saturation 100%. Laboratory values were notable for the following: WBC-5.7, Hgb-8.4, Hct-27.5, creatinine-0.73, glucose-94. The patient was empirically started on intravenous antibiotics (Unasyn) for an abdominal wall cellulitis. A chest x-ray was negative. Computed Tomography (CT) scan of abdomen/pelvis showed only fatty liver infiltration and a left adnexal cyst. Their clinical diagnosis was panniculitis or inflammation. All cultures were negative. The patient remained afebrile, hemodynamically stable and improved clinically. The patient was discharged to continue oral antibiotics (Augmentin) as an outpatient.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

According to the documentation, the patient presented with some non-specific upper respiratory symptoms believed to be an asthma exacerbation and panniculitis. Otherwise, she was afebrile, hemodynamically stable, with unremarkable laboratory results including WBC. The chest x-ray was negative and there was no evidence of a systemic infection. The patient was diagnosed with panniculitis - a non-specific inflammatory dermatologic finding. She had some chronic issues including an adnexal mass and infra-umbilical hernia - both appropriately recommended for follow-up as an outpatient. Based on above findings, patient was stable for outpatient management following evaluation in the emergency department. The medical necessity is not substantiated.