Diagnosis: right lower extremity ulcer

Treatment: hospital admission

The insurer is denied coverage for hospital admission.

The denial is overturned.

This male patient has a history of chronic kidney disease (CKD), hypertension, hyperlipidemia, vascular disease, diabetes mellitus type 2, and chronic right lower extremity ulcer.

The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for right lower extremity wound/cellulitis. Magnetic Resonance Imaging (MRI) of fibula/tibia was negative for any osseous pathology. He underwent debridement of the wound. Nephrology consulted for renal insufficiency. Renal ultrasound was negative. Infectious Diseases recommended continuation of antibiotics. Vascular Surgery advised continue wound care. The patient improved clinically, remained afebrile and hemodynamically stable. He was discharged to continue oral antibiotics (Augmentin and Bactrim) and wound care as an outpatient.

According to documentation, patient was referred to the hospital from wound center for worsening lower extremity ulcer. Patient was otherwise afebrile, but with elevated blood pressures. Laboratory results were notable for worsening renal insufficiency. Of note, patient's symptoms progressed despite a 10-day course of antibiotics.

Based on above findings including failure of outpatient management in a high-risk patient, hospital admission was medically necessary for administration of intravenous antibiotics and surgical debridement.

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 hospital admission is overturned. The medical necessity is substantiated.