Diagnosis: Skin Disorders-Cellulitis
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary.
The reviewer has overturned in whole the health plans determination.

The patient has a past medical history significant for obesity that required gastric sleeve surgery and came to the emergency department with complaints of fever, chills, leg swelling, and redness that started after he had a pedicure.
The patient was seen by his primary care physician who started him on Augmentin because of the lower extremity cellulitis. The patient stated that he took Augmentin, but his symptoms did not improve.
There was right leg swelling, and erythema up to the knee. The rest of the physical exam was unremarkable. The patient was admitted to the hospital and received treatment with intravenous antibiotics for right lower extremity cellulitis. In the hospital, the patient was seen by an infectious disease specialist. It was recommended to continue treatment with intravenous antibiotic Cefazolin, elevation of the right lower extremity, and monitoring of inflammatory markers. As a result of the treatment with intravenous antibiotics, the patient's clinical condition gradually improved. The patient was transitioned to oral antibiotics and discharged home.

The admission at the acute inpatient level of care was appropriate due to lack of response to treatment with oral antibiotics, progression of the infection, and relatively large area affected by cellulitis. The review of medical records clearly demonstrated the failure of outpatient therapy. Based on the initial evaluation, there was no significant improvement in the patient's symptoms despite taking Augmentin, which is one of the common antibiotics used to treat cellulitis and soft tissue infections. Based on the records, the patient took it for at least 48 hours. Considering the significant progression of cellulitis that started in the foot and spread up to the knee, the initiation of outpatient intravenous therapy was not appropriate based on the acuity and the size of the area affected.
The determination coincides with Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition criteria for cellulitis. These criteria were attached to the chart for review. The patient met these criteria.