Diagnosis: Cellulitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is an adult with past medical history of peripheral arterial disease and diabetes mellitus, who presented to the emergency department with complaints of left lower extremity erythema and swelling.

Vitals on presentation included: Temperature 97.5 degrees Fahrenheit, Blood Pressure 126/73, Pulse 100, Respiratory Rate 18, oxygen (O2) saturation 99% (percent) on Room Air. Laboratory results included the following: White blood cell (WBC) count 10.31, hemoglobin (Hgb) 16.9, hematocrit (Hct) 48.7, creatinine 0.56, glucose 240.

The patient was started empirically on intravenous antibiotics (Zosyn) for possible lower extremity cellulitis. Infectious Diseases consulted and recommended adjustments in antibiotics. X-ray of tibia/fibula showed no acute radiographic osseous pathology. She remained afebrile and clinically and hemodynamically stable. The patient was discharged to continue oral antibiotics (Cefadroxil) as outpatient.

According to documentation, the patient presented with lower extremity cellulitis. Otherwise, the patient remained afebrile and hemodynamically stable. Laboratory results showed normal WBC. Cultures remained negative. The patient had no evidence of a disseminated infection and no surgical intervention was required. Based on above findings, the patient did meet criteria for observation level of management. She did not fulfill criteria for acute hospital admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is not substantiated.