Diagnosis: Left Foot Cellulitis

Treatment: Inpatient emergency admission

The insurer denied coverage for inpatient emergency admission.

The denial is upheld.

This patient is a female with past medical history significant for morbid obesity, hypertension, congestive heart failure, and lymphedema who presented to the emergency department with complaints of shortness of breath, and left foot swelling and pain. Vitals on presentation included: Temperature 98.8, Blood Pressure 132/84, Pulse 105, Respiratory Rate 20, oxygen (O2) saturation - 97% (percent) on room air. Laboratory results included the following: white blood count (WBC) - 9.1, hemoglobin (HGB) - 11.5, hematocrit (HCT) - 37.4, creatinine - 0.83, glucose - 103, B-type natriuretic peptide (BNP) <10.

This patient was admitted to the hospital for a possible left foot cellulitis. She was empirically started on antibiotics (cefazolin and doxycycline). Chest x-ray (CXR) was negative. X-ray of foot showed no dislocation, no fracture. All cultures were negative. The patient had a hypertensive episode that was believed to be secondary to anxiety. The patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient management.

According to documentation, the patient presented with left foot swelling. Otherwise, she was afebrile and hemodynamically stable with unremarkable laboratory results including a normal WBC. Imaging studies including CXR and foot x-rays were also negative. Based on above findings, the patient did not meet criteria for acute inpatient care.

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

Based on the above, the medical necessity for the inpatient emergency admission is not substantiated. The insurer's denial is upheld.