Diagnosis: chronic cellulitis

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is overturned.

This patient is a male with multiple medical problems that presented to the hospital with bilateral leg pain due to non-healing ulcers. The patient has a history of peripheral vascular disease, non-ischemic systolic congestive heart failure with a left ventricular ejection fraction (LVEF) of 17%, severe mitral regurgitation and polysubstance abuse. The patient was hospitalized for acute on chronic cellulitis, and was noted to have worsening lower extremity edema. The patient's brain natriuretic peptide (BNP) was elevated and treatment for an acute on chronic exacerbation of systolic congestive heart failure was initiated. Following diuresis, the patient's condition improved.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. This patient presented with bilateral leg pain and swelling along with decompensated congestive heart failure. Given the multiple ulcers on this patient's leg, worsening pain and fluid overload as demonstrated by an elevated BNP level and physical examination, this patient could not have been managed at an alternate level of care and required inpatient treatment/follow up. There have been several studies including a meta-analysis of more than 50,000 patients demonstrating poor outcomes for patients that are discharged from the emergency department after presenting with congestive heart failure. These findings were true in both systolic and diastolic congestive heart failure (CHF). In conclusion, acute inpatient admission was necessary to treat acute on chronic heart failure that resulted in lower extremity edema, pain and acute on chronic cellulitis.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.