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201906-118096

2019

Empire Healthchoice Assurance Inc.

Indemnity

Skin Disorders

Inpatient Hospital

Medical necessity

Upheld

Case Summary

The patient has a hx of hypertension (HTN), morbid obesity, obstructive sleep apnea (OSA) non-compliant with continuous positive airway pressure (CPAP) who presented to the emergency department 1/23/19 with 1 month history of R (right) leg swelling, redness and pain as well as worsening dyspnea. The patient was admitted for cellulitis treatment and started on vancomycin and piperacillin/tazobactam.

The health plan's determination is upheld. The inpatient stay is not medically necessary. The patient presented with LE cellulitis and was admitted for IV antibiotics and concern for untreated OSA versus obesity hypoventilation. The patient had significant comorbidities; however, was afebrile and had not previously tried abx (antibiotics) for edema/cellulitis. The patient did not meet acute inpatient status and could have been safely managed at a lower level of care.

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