Diagnosis: cellulitis.
Treatment: Inpatient hospital.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

This was a male with history of anxiety, depression, post-traumatic stress disorder (PTSD) and intravenous drug use who presented to the hospital with complaint of left arm pain and swelling that began 1 day prior. Vital signs were temp 98.5 F (Fahrenheit), pulse 79, respirations 19, and blood pressure (BP) 137/83. Physical examination revealed diffuse swelling from the elbow down to the hand, tender to the touch around the left forearm as well as induration. Abnormal laboratory values included aspartate aminotransferase (AST) 44. Urine toxicology was positive for cannabis. Ultrasound of the left arm showed a superficial vein thrombosis and a well-defined structure concerning for a hematoma, mass or cyst. The patient was admitted and started on intravenous antibiotics. The patient decided to the leave the hospital against medical advice.

The inpatient hospital admission was not medically necessary. This patient presented to the hospital with left arm pain and swelling. There was no evidence of hemodynamic instability. There was no evidence of a severe infection or sepsis. There was no evidence of failure of outpatient therapy with antibiotics. There was no evidence of severe pain requiring inpatient care. The patient did not require any surgical intervention. The patient was able to tolerate oral intake. Based on the available medical records, the patient did not have any clinical needs that warranted inpatient level of care.