Diagnosis: Right Foot Cellulitis

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a male with a past medical history significant for diabetes mellitus, neuropathy, peripheral vascular disease, and status post left foot amputations, who was referred to the Emergency Department for possible osteomyelitis. The patient complained of right groin tenderness and subjective fevers. Vitals on presentation included: Temperature 99.6 Fahrenheit, Blood Pressure 138/80, Pulse 98, Respiratory Rate 17, and Oxygen saturation 95 percent on room air. Laboratory results included the following: White blood cell count-12.3, hemoglobin-12.6, hematocrit 39.1, creatinine-0.83, and glucose-106. The patient was admitted for possible osteomyelitis. He was empirically started on intravenous antibiotics (vancomycin and Unasyn). X-ray of the left foot showed no evidence of acute fracture, no radiographic evidence of osteomyelitis. Right foot x-ray was suggestive of gouty arthropathy of the first metatarsophalangeal joint. Culture remained negative. He underwent a bedside debridement of the left 1st and 2nd toe. He remained afebrile and hemodynamically stable. The patient was discharged to continue oral antibiotics (Bactrim) as outpatient.

According to documentation, the patient was admitted for possible cellulitis versus osteomyelitis. Otherwise, he was afebrile, hemodynamically stable. Laboratory results showed only a mild elevated white blood cell count, which resolved the following day. The patient had no evidence of acute osteomyelitis or a disseminated infection. The patient underwent a bedside debridement. Based on the above findings, the patient met criteria for observation level of management. He did not meet criteria for acute hospital admission.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.