Diagnosis: Sinusitis; right hand cellulitis
Treatment: inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This patient is a female with past medical history significant for a liver disease, polysubstance abuse, and status post broken nose due to a recent fall, who presented to the Emergency Department with complaints of facial pain and right hand erythema. The patient's vitals on presentation included: Temperature 98.1 F, Blood Pressure128/82, Pulse-107, Respiratory Rate 18, O2 sat-100% on Room Air. Laboratory results included: WBC-7.47, Hgb-10.5, Hct-32.7, creatinine-0.66, glucose-106. The patient was started empirically on IV antibiotics (Vancomycin and Unasyn) for possible right hand cellulitis. CTA of the head showed opacification of the left maxillary sinus. CT scan of the spine showed mild degenerative disc disease. X-ray of the hand showed no acute fracture or evidence of osteomyelitis. Infectious Diseases consulted. The patient remained afebrile, hemodynamically stable and clinically improved. The patient was discharged on oral antibiotics to follow-up as an outpatient.

According to documentation, the patient presented with possible sinusitis from a previous nose fracture and right hand cellulitis. Otherwise, she was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. There was no evidence for a disseminated infection. The patient met criteria for observation level of care. Based on above finding, the patient did not meet criteria for acute inpatient admission.
The health plan acted reasonably with sound medical judgment and 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.