Diagnosis: Rash.
Treatment: Full Hospital Admission.
The insurer denied coverage for full hospital admission.
The denial is upheld.

The patient is a female with a past medical history significant for obesity and COVID(Coronavirus Disease 2019) infection who presented to the emergency department with complaints of bilateral inner thigh rash that spread to her face, leg, arms and abdomen.

Vitals on presentation included: Temperature 99.9 Fahrenheit, Blood Pressure 124/81, Pulse 87, Respiratory Rate 20, Oxygen (O2) saturation-98% on Room Air. Laboratory values were notable for the following: White blood cell count (WBC) 18.8, hemoglobin (Hgb) - 13, hematocrit (Hct) - 42.4, platelets-590, creatinine-0.98, glucose-115, D-dimer 2.14, C-reactive protein (CRP)-4.5, lactate dehydrogenase (LDH)-377, procalcitonin -<0.10.

The patient was admitted for evaluation of rash. She was started on intravenous (IV) fluids and IV clindamycin. Dermatology consulted and recommended topical ointments including mupiricin, betamethasone, and hydrocortisone. The patient improved clinically, remained afebrile, hemodynamically stable; the patient was discharged to continue outpatient management on oral antibiotics.

According to documentation, the patient presented a rash of unclear etiology. Otherwise, she was afebrile, hemodynamically stable with stable O2 saturation on room air. The patient was recovering from COVID infection, chest x-ray (CXR) showed no abnormalities. Laboratory results likely reflected changes associates with prior diagnosis of COVID. The patient had been on prednisone as an outpatient, which likely contributed to elevated WBC; procalcitonin was negative. The patient had no evidence of a disseminated infection and no surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management; the patient did not fulfill criteria for acute care hospitalization.

The health plan did act reasonably with sound medical judgement in the best interest of the patient.

The insurer's denial of coverage for the Full Hospital Admission is upheld. Medical Necessity is not substantiated.