Diagnosis: Skin Disorders.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The health plan's determination is upheld.

This is the case of a male who presented to the emergency department (ED) with a 3 day history of left forearm pain, rash, and swelling. Pain occurred on extension of the left elbow and redness and swelling of the left forearm had increased over the past 3 days. Review of symptoms (ROS) was negative for fever, recent trauma, or similar swelling in the past. Patient problem list includes obesity, eczema, and acanthosis nigricans.
ED vitals were temperature (T) 37.2 Celsius (C), heart rate (HR) 99, respiratory rate (RR) 18, blood pressure (BP) 120/80, oxygen (O2) saturation 100% on room air. The patient's weight was 275 lbs., and the pain score was 5/10. Physical exam was notable for 8-10 centimeter (cm) x 3-5 cm erythema, tenderness, and indurated swelling of the ventral aspect of the left forearm. Pain was elicited with extension of the left elbow. There was no associated lymphadenopathy. Complete blood count (CBC) showed white blood cell (WBC) count = 13.7 with normal differential, C-reactive protein (CRP)=6.3. The patient was given a dose of intravenous (IV) clindamycin and was admitted for intravenous (IV) antibiotics to treat a diagnosis of cellulitis.
At issue is whether this inpatient admission was considered medically necessary.

The health plan's decision is upheld.

The requested inpatient hospitalization is not considered medically necessary. This patient could have been adequately treated at a lower level of care. He was an otherwise healthy teenager with stable vital signs and ability to tolerate and oral diet.
He presented with 3 days of left forearm redness, pain, and swelling. There was no fever, vomiting, or history of trauma. The patient did not have immune compromise or other underlying medical condition. Laboratory evaluation showed elevation of WBC and CRP, consistent with skin infection.
Per Milliman Care Guidelines (MCG) Pediatric Cellulitis criteria, this patient did not meet criteria for inpatient level of care. Additionally, per Infectious Disease Society of America (IDSA) Guidelines cited below, "Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability (mild nonpurulent; Figure 1) (strong, moderate). Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing (moderate or severe nonpurulent; Figure 1) (strong, moderate)."