Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscess.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male child that was referred to the ED (emergency department) by his dentist for evaluation of possible dental abscess. The child presented with two-day history of tactile fever and worsening left facial swelling. He was seen by his dentist on the day of admission and was referred to the ED (emergency department) for procedural sedation.

The patient's vital signs included temperature 38.9 C (Celsius), heart rate 102/minute, respiratory rate 15/minute, and blood pressure 120/66 mmHg (millimeters of mercury). Examination was significant for no acute distress, marked left cheek swelling, swelling of the left upper gingiva with tenderness to palpation over the posterior dentition, moist mucous membranes, clear lungs, and non-focal neurologic exam. Laboratory evaluation revealed leukocytosis with WBC (white blood count) 15K (thousand) and elevated CRP (C-reactive protein) 2.75. COVID testing and blood culture were obtained.

The patient was treated with ibuprofen and consultation was placed with Oral Maxillofacial Surgery. Under ketamine sedation, the abscess was drained. Wound culture was obtained, and the child was treated with Toradol, normal saline bolus, and Unasyn.

The patient was admitted for ongoing management, with orders including antipyretics, maintenance IV (intravenous) fluids, Unasyn, soft food diet, and follow-up cultures. He was transitioned to Augmentin in anticipation of discharge, to follow-up in the outpatient clinic.

No, the Inpatient admission was not medically necessary in this case. The patient could have been safely managed at a lower level of care.

Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient.

This child presented first to the dentist and then to the ED (emergency department) with signs and symptoms consistent with facial cellulitis and dental abscess. Although he had fevers, he was otherwise hemodynamically stable with no evidence of impending sepsis. Following abscess drainage in the ED (emergency department), he was treated with parenteral antibiotics in the hospital. While it was not unreasonable to monitor this child in the hospital for resolution or progression of symptoms, he did not require acute inpatient admission. He could have been safely managed at lower level of care, such as observation.