Diagnosis: cellulitis

Treatment is an inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld

The patient with a past medical history significant for substance abuse, hypertension, and benign prostatic hyperplasia, presented to emergency department with complaints of left lower leg swelling and pain.

Vitals on presentation included: Temperature 98.1 degrees F (Fahrenheit), Blood Pressure 144/91, Pulse 108, Respiratory Rate 17, and oxygen saturation 100% on room air. Laboratory results included the following: WBC (white blood cell count) 6.3, HGB (hemoglobin) 11.5, HCT (hematocrit) 35.6, creatinine 0.93, glucose 98, and lactic acid 0.96.

The patient was administered Narcan while in the emergency department for lethargy. He started empirically on intravenous antibiotics (vancomycin and cefepime) for left leg cellulitis. An X-ray of the leg showed mild degenerative changes and soft tissue swelling but no osteomyelitis. He remained afebrile and hemodynamically stable and left the hospital against medical advice (AMA).

According to documentation, the patient was admitted for a possible cellulitis. Otherwise, he was afebrile, hemodynamically stable. Laboratory results were unremarkable including a normal WBC. There was no evidence of a disseminated infection, no surgical intervention was required, and the patient was not immunocompromised.

Prior determination of denial of coverage for inpatient hospital services is upheld. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.