Diagnosis: Right foot pain and swelling.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is overturned.

The patient is a male whose inpatient admission is under review. The patient has a history of HTN (hypertension), a-fib (atrial fibrillation), and left foot osteomyelitis. He presented to the hospital with right foot pain and swelling after having failed outpatient treatment with ten days of Augmentin. The patient's presentation was notable for worsening erythema, swelling in right first toe, and pain in toe.

In the ER (emergency room), the patient's vitals were as follows: T (temperature) - 97.6, P (pulse) - 110, RR (respiration rate) - 18, and BP (blood pressure) - 164/83. On general examination, the patient was noted to be NAD (no acute distress). Examination of the patient's chest was normal. Examination of the patient's CVS (cardiovascular system) revealed tachycardia. Examination of the patient's abdomen was normal. Examination of the patient's extremities reveal swelling and erythema of the right foot, open wound in right first toe.

The patient's labs were as follows: WBC (white blood count) - 13.5 (high), Hg (hemoglobin) - 15.1, Hct (hematocrit) - 42.1, Plt (platelets) - 135, Na (sodium) - 139, K (potassium) - 3.8, Cl (chloride) - 106, CO2 (carbon dioxide) - 22.8, BUN (blood urea nitrogen) - 16, and Cr (creatinine) - 1.2.

The patient's foot x-ray revealed amputation of first digit at distal proximal phalanx, as well as soft tissue swelling and irregularity.

In the ER, the patient was thought to have right foot cellulitis and ulcer, and he was admitted for IV (intravenous) antibiotics and management. An MRI (magnetic resonance imaging) ruled out osteomyelitis, but did show an abscess, which was incised and drained. Afterwards, the patient was discharged on PO (oral) antibiotics.

Yes, the Inpatient admission was medically necessary.

Inpatient admission was indicated for the following reasons: 1) Systemic signs of infection (tachycardia and elevated WBC [white blood cell] count) (1), and 2) Failure of outpatient therapy (1), as noted in the clinical summary, above.

Thus, this admission was warranted, supported by Infectious Diseases Society of America (IDSA) guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.