Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is an adult patient with a past medical history significant for coronary artery disease, hypertension, hyperlipidemia, left lower extremity deep vein thrombosis, and obesity who presented to the emergency department with complaints of fever, chills, and malaise.

Vitals on presentation included: Temperature 103 degrees Fahrenheit (F), Blood Pressure 121/80, Heart Rate (HR) 118, Respiratory Rate 25, oxygen (O2) saturations 97% (percent) on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 12.4, Hemoglobin 12.2, Hematocrit 36.4, glucose 119, and creatinine 1.13.

The patient was empirically started on intravenous antibiotics (vancomycin and ceftriaxone) for a left lower extremity cellulitis. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (cephalexin) as an outpatient.

According to documentation, the patient presented with a fever (103 F), tachycardia (HR 118), and laboratory results notable for leukocytosis (WBC 12.4) and left lower extremity cellulitis.
Based on the above findings in a high-risk patient with multiple comorbid conditions, a hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient admission is substantiated.