Diagnosis: Foot ulcer past medical history of diabetes with neuropathy, hypertension, hyperlipidemia and peripheral vascular disease

Treatment: Inpatient admission, bloodwork, intravenous medication

The insurer denied the inpatient admission. The denial was upheld.

This patient was seen in the Emergency Department for acute swelling and pain to the right foot with difficulty ambulating. The patient had a punched-out ulcer on the plantar surface of right foot 1 cm x 1 cm which he indicated had been present since about 7 months. The patient was admitted two months prior for similar issues and was discharged with oral cefdinir. The patient was previously treated with IV antibiotics x3 days 6 weeks prior and had been on intermittent oral antibiotics with fluctuating improvement in symptoms. The patient stated that the foot pain and swelling acutely worsened prior to presentation. The patient received ceftriaxone, Flagyl and doxycycline in the emergency department. The patient was admitted to receive treatment with IV ceftriaxone and vancomycin as well as oral doxycycline. X-rays and venous scans were negative. Wound debridement was completed at bedside.

The medical literature indicates that inpatient admission is indicated for patients with cellulitis if there is failure of outpatient therapy as indicated by progression or no improvement after adequate trial minimum of 48 hours, with longer period for stable lower extremity infection as well as adequate antibiotic regimen and outpatient intravenous therapy is not appropriate. Inpatient care may also be indicated if there is limb threatening infection, clinical presentation is judged to require intensity of patient monitoring that cannot be provided at an outpatient level care, high risk co-morbid condition, bacteremia, altered mental status is severe persistent, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection, oral cellulitis, cutaneous gangrene, periorbital or perineal infection that is severe progressive, severe pain requiring acute inpatient management, inability to maintain oral hydration or compartment syndrome monitoring.

The documentation indicated that the patient has had a previous trial and failure of outpatient antibiotic medications. The patient has had a fluctuation in symptoms. However, there was no indication that the patient had progression or no improvement after an adequate trial of a minimum of 48 hours. Furthermore, there was no indication that the patient could not utilize outpatient intravenous. Therefore, the patient's condition was appropriate for a lower level of care rather than inpatient level care.