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202211-156224

2023

Fidelis Care New York

Medicaid

Infectious Disease

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) left leg pain and erythema after a fall and scrape; the patient received an outpatient antibiotics prescription prior to admission but did not fill it. Her vital signs were unremarkable. The physical exam was notable for left lower extremity (LLE) edema and erythema, no acute distress. Lab work was notable for an elevated erythrocyte sedimentation rate (ESR) / C-reactive protein (CRP). Imaging studies included a chest x-ray (CXR) which was unremarkable, left lower extremity (LLE) radiographs showed tissue swelling, dopplers were negative for deep vein thrombosis (DVT) bilaterally, a computed tomography (CT) scan of the LLE showed an abscess. The patient was diagnosed with left lower extremity (LLE) cellulitis and was treated with intravenous (IV) antibiotics. General surgery was consulted and recommended an incision and drainage (I&D) for the abscess, which the patient refused. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with c/o left leg pain and erythema after a fall and scrape. She was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with intravenous (IV) antibiotics and surgical consultations, and this could have been safely provided at a lower level of care. Observation is ideal for the management of cellulitis infections because it allows frequent reevaluation to assess response to therapy while avoiding inpatient admission. Overall, this patient could have been safely treated at a lower level of care.

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