Diagnosis: Left ankle cellulitis

Treatment: Inpatient admission

The insurer denied the inpatient admission. The denial was upheld.

The patient is a male with a past history of hypertension and recent burn injury to his left lower extremity. He presented to the emergency department with complaints of left ankle swelling. His vital signs on presentation were: temperature 37.1C, blood pressure 142/87, pulse 112, respiratory rate 18. The patient was started empirically on intravenous antibiotics (Unasyn) for a left ankle cellulitis following a recent burn injury. A Plastic Surgeon evaluated the patient for partial thickness burns and recommended warm soapy washes with Silvadene cream and smoking cessation. The patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics as an outpatient.

According to documentation, the patient presented with a left ankle cellulitis. Otherwise, he was afebrile, hemodynamically stable with no significant laboratory abnormalities. The Plastic Surgeon evaluated the patient and recommended localized wound care; no surgical intervention was deemed necessary. Additionally, patient had no evidence of a systemic infection, no significant co-morbid conditions, and was capable of tolerating oral intake. Based on above findings, this patient did not meet criteria Milliman Care Guidelines criteria using the guidelines of Cellulitis (ORG: M-70) and Burn, Major, Noncritical for acute inpatient admission.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.