Diagnosis: Fever, Rash, Cellulitis of Left Thigh.
Treatment: Inpatient Hospital Admission.

The insurer denied the inpatient hospital admission. The health plan's determination is overturned.

The patient is a female who presented to the emergency department (ED) with a 1 day history of fever and rash on the left thigh. She had a fever of 100.6 orally that was noted at home, then a rash on the thigh thought to be from an insect sting.

Her ED vital signs were temperature 38.9 degrees Celsius, heart rate (HR) 155, blood pressure (BP) 106/75, respiratory rate (RR) 20 and her peripheral capillary oxygen saturation (SpO2) was 97 percent (%) on room air. The physical examination noted areas of induration on the left thigh, 9 by 7 centimeters (cm) and 7 by 6 cm in size with tenderness and warmth. Her white blood cell count (WBC) was 9.9 with mild neutrophilia. Her erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were slightly elevated. The patient was started on intravenous (IV) Unasyn, and she was admitted to the hospital for further management.

The health plan, in its determination of medical necessity, did not act reasonably or with sound medical judgment in the best interest of this patient.

The inpatient hospital admission was medically necessary for this patent. The patient presented with fever and rash consistent with acute cellulitis to the left anterior thigh. The patient showed systemic signs of illness, with concern for systemic inflammatory response syndrome (SIRS) and she required close monitoring and IV antibiotic treatment to ensure no decompensation. Given the concern for SIRS, an inpatient admission with IV antibiotics was medically necessary in this case.

The health plan's determination of medical necessity is overturned in whole.