Diagnosis: Left lower leg cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male with past medical history significant for chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus, and hyperlipidemia who presented to the emergency department with complaints of bilateral lower extremity pain and swelling. Vitals on presentation included: Temperature 36.5 C, blood pressure 129/79, pulse 100, respiratory rate 16, and oxygen saturation 97% on room air. Laboratory values were notable for the following: WBC-9.83, Hgb-10.1, Hct-32.9, creatinine-0.79, glucose-108, CRP-18.11, ESR>130.

The patient was admitted for a left lower leg cellulitis. He was empirically started on intravenous antibiotics (vancomycin). Ultrasound of the lower extremity was negative for deep vein treatment (DVT). Infectious Diseases consulted for cellulitis and penicillin allergy. Of note, patient developed swelling in left side of face, cheek, and lips suspected to be an allergic reaction to Levaquin. He responded to IV Benadryl. The patient was seen by an Allergist consult who recommended antibiotic options. Vascular Surgery also evaluated patient for peripheral vascular disease. All cultures were negative. The patient remained afebrile, hemodynamically and clinically stable. The patient had a midline catheter placement for home intravenous antibiotic infusion (vancomycin).

According to documentation, patient was admitted for a left lower extremity cellulitis. He was otherwise afebrile, hemodynamically stable with unremarkable laboratory findings including a normal WBC. Although ESR and CRPs were noted to be increased, these non-specific findings likely reflected chronic inflammation. The patient had a localized infection with no failure of outpatient intervention and he did not require surgical intervention. He had an allergic reaction to Levaquin as a result of his hospital stay. Based on above findings, patient did not meet criteria for acute inpatient admission.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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