202109-141538
2021
Empire Healthchoice Assurance Inc.
Indemnity
Skin Disorders
Inpatient Hospital
Medical necessity
Overturned
Case Summary
Diagnosis: Left index finger cellulitis.
Treatment: Full hospital admission.
The insurer is denied coverage for full hospital admission.
The denial is overturned.
This female patient has a history of scleroderma, gastroesophageal reflux disease (GERD), Raynaud's, and interstitial lung disease (ILD).
The patient was started empirically on intravenous antibiotics (vancomycin and ceftriaxone) for a left index finger cellulitis. X-ray of the hand did not show any soft tissue abnormalities or any osseous erosive changes. Infectious Diseases consulted and recommended magnetic resonance imaging (MRI) of the hand which she could not tolerate due to underlying anxiety. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics (Augmentin and minocycline) as an outpatient.
According to documentation, patient was admitted with a left index finger infection. She was afebrile but tachycardic (heart rate-103). Laboratory results were notable for leukocytosis (WBC-17.3). Based on above findings in a high-risk patient immunocompromised with documented failure of two courses of outpatient antibiotics, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation.
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 full hospital admission is overturned. The medical necessity is substantiated.