Diagnosis: Cellulitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

An adult patient with no significant past medical history presented to the Emergency Department (ED) with complaints of fevers, chills, and right lower leg erythema and swelling. The patient's vital signs on ED presentation included: Temperature max 103.1 F, Blood Pressure 158/89, Pulse 115, Respiratory Rate 18, Oxygen Saturation 97% on Room Air. The patient's laboratory results included the following: white blood cell (WBC) 11.5, hemoglobin 14.5, hematocrit 43.1, creatinine 0.7, and glucose 119. The patient was started empirically on intravenous (IV) fluids and IV antibiotics (i.e., vancomycin, ceftriaxone, Flagyl) for lower extremity infection. The patient's computed tomography (CT) scan of the lower extremity showed changes suggestive of cellulitis, but no evidence for osteomyelitis. All cultures remained negative. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue outpatient management on oral antibiotics (i.e., doxycycline).

According to documentation, the patient presented with worsening right lower leg cellulitis. The patient had a fever of 103.1 F, tachycardia (heart rate of 115), hypertension (blood pressure of 158/89), and laboratory results showed leukocytosis (white blood cell count of 11.5) and elevated glucose. Based on these abnormal findings, inpatient admission was medically necessary for the administration of intravenous antibiotics and further monitoring.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for inpatient admission is substantiated. The insurer's denial should be overturned.