Cellulitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for inpatient hospital admission and care. Regional lymphadenopathy is not uncommon in childhood and is typically the result of infection in the lymph node(s) or the drainage area. Many patients have history of recent viral infection, in which case no further management is indicated. If bacterial infection is suspected, possibilities may include retropharyngeal abscess, peritonsillar abscess, and dental abscess. In these cases, antibiotic coverage for staphylococcus and streptococcus is necessary. Patients unable to tolerate fluids may require intravenous (IV) fluids and parenteral antibiotic therapy. Development of additional clinical findings may indicate Kawasaki disease, creating another treatment pathway.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. At the time this patient presented to the hospital, she was tachycardic and afebrile. She was on antipyretics with reported high fevers at home. There was a known source of infection from her left chest cellulitis. Although not formally diagnosed on the medical record, the patient met the criteria for sepsis, which was referenced in the history and physical with the collection of blood cultures, lactate, and procalcitonin. The patient was not treated with fluid resuscitation. The Infectious Diseases Society of America (IDSA) practice guidelines for the management of skin and soft tissue infections recommends systemic antibiotics for moderate, nonpurulent cellulitis, as in this case.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for abdominoplasty, breast reconstruction, complex trunk repair, bilateral brachioplasty and liposuction. According to the American Society of Plastic Surgeons (ASPS) state, “Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty…A cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction.” In this case, the patient reported having undergone a panniculectomy, and did not believe that she underwent liposuction. However, the records support an abdominoplasty and liposuction as having been performed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and continuous coverage of a skilled nursing facility, level II care from 8/22/18 forward. Per a study, mild to moderate nonpurulent skin/soft tissue infections such as limb cellulitis are treated with intravenous and/or oral antibiotics. Another study note that lymphedema is a chronic condition that is managed with interventions such as manual decompression, limb compression pumps, compression wrapping/taping, compression sleeves and skin care The records in this case indicate that the patient was on oral antibiotics upon admission to the skilled nursing facility on 7/19/2018, with an order for a course of one week. Nursing evaluation did not note any significant wounds, skin lesions or other need for skilled nursing care with respect to his admission diagnosis of cellulitis.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving cellulitis, then check the rights and deadlines that apply to your plan.