Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Body Fluid and Higher Than Normal White Cell Level
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female without any significant past medical history. She was bought to the emergency room by ambulance with complaints of throat pain and difficulty swallowing for three days. The patient's symptoms gradually worsened to involve the neck and both ears, and she also developed difficulty opening her mouth and also noted subjective fever before presentation to the emergency room.
On presentation to the emergency room, the patient was noted to have a fever, with a temperature of 101.7 Fahrenheit. She was also noted with trismus. The patient was noted to have trismus; unable to open mouth completely; posterior pharynx could not be visualized, and the patient was noted to be unable to swallow liquids. The patient's labs showed WBC (white blood count) 17.1k (thousand) (Neutrophils 83% [percent]) and anion gap 17. CT (computed tomography) scan revealed increased edema in the anterior cervical space and pharynx. The patient was treated with IV (intravenous) fluid normal saline bolus, IV (intravenous) antibiotic Unasyn and IV (intravenous) solumedrol and Tylenol. The patient required urgent evaluation by ENT (otolaryngology), who advised IV (intravenous) antibiotics and steroid taper, but no immediate surgical intervention was done. The patient was admitted. She was started on treatment as noted above, and she was continued on IV (intravenous) antibiotics and steroid taper. The patient continued to improve and was discharged 2 days later.

The Inpatient Hospital Admission was medically necessary.

The patient had presented with acute and progressive symptoms involving throat pain, pain to the neck and ears and inability to open mouth. Examination in emergency room also showed that patient was unable to swallow liquids due to edema. Complete evaluation of the posterior pharynx was also not completely possible due to inability to open mouth and the edema. Labs showed a noticeable WBC (white blood cell) count of 17k (thousand), indicative of definite infection with systemic involvement and possible sepsis. The patient's CT (computed tomography) scan also showed edema involving the pharynx and anterior cervical space. The patient was evaluated by ENT (otolaryngology) and advised antibiotics and steroid taper. In view of the above presentation and severity of findings on clinical evaluation, lab results and CT (computed tomography) scan findings, admission to inpatient hospital stay was medically appropriate to ensure that the patient was adequately treated with appropriate IV (intravenous) medications - including antibiotics and steroids. Inpatient admission was also necessary and appropriate to ensure there was adequate and close monitoring of the patient's condition. The patient already had difficulty with swallowing liquids on presentation in the emergency room, and inpatient monitoring was needed to ensure that any progression of this problem is immediately addressed, and that the patient is provided the appropriate treatment if progression were to have occurred. Outpatient or observation stay management was not appropriate for this patient in view of the severity of symptoms and to avoid the possibility of delay in additional treatment measures if needed, if the symptoms were to have worsened. Based on the severity of the patient's presentation and overall clinical picture, it was reasonable to conclude that the patient would have required at least two to three days of inpatient stay before improvement could be expected such that discharge could be considered. In view of this, inpatient hospital stay was medically necessary.