Skin Disorders
Inpatient hospital

Diagnosis: Cellulitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male who presented to the hospital with complaints of pain in the right hand associated with swelling. Reportedly, he had a physical altercation. The patient noticed swelling in his right hand. It became painful. Subsequently, the patient developed a fever.
When seen by the admitting physician, the patient had several abrasions to his hand and came to the hospital for evaluation. The initial evaluation included an x-ray of his hand. It did not show any evidence of fractures. The admitting physician stated that the patient had leukocytosis. This prompted the administration of intravenous antibiotics in the emergency department.

The inpatient hospital stay was not medically necessary for this patient. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care.
Overall, during this hospital stay, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was very short and was within the scope of a lower level of care.
A careful review of the patient's records demonstrated that the patient did not meet the nationally recognized criteria for admission at the acute inpatient level of care. Even though the patient possibly had a small cutaneous abscess, there was no surgical procedure performed.