Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Left Facial Cellulitis

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

This is an adult female who presented with respiratory distress and abscess to left side of face. The patient was brought in by emergency medical services (EMS) with concerns for impending airway loss. The patient stated the face had been swollen for 1 day. She had tooth pain and then noted her cheek swelling. She had planned to go to the dentist. She had swelling to the left side of her face, left lips, and cheek. She had abnormal dentition with dental caries present. The assessment was patient with respiratory distress with left sided facial swelling without uvula or tongue swelling. The plan was oxygen, computed tomography (CT) maxillofacial, Unasyn, and oral and maxillofacial surgery (OMFS) consult. CT revealed extensive soft tissue swelling in the left side of the face consistent with cellulitis without a discrete abscess noted.

OMFS saw the patient and noted that the patient reported having pain for a year and the swelling continued to worsen over the last 2 days with dysphagia and odynophagia. The patient appeared groggy, falling asleep in between questions. There was left sided facial pain and asymmetry with lesions noted intraorally. There was left midface and lower facial edema with induration, warm to touch and tender to palpation. There was grossly decayed left posterior dentition and left buccal/vestibular edema. The impression was extensive soft tissue swelling in the left side of the face consistent with cellulitis. The plan was to admit to OMFS and plan emergency surgical intervention.

As per the discharge summary, the patient had left facial swelling and difficulty breathing and swallowing. She was started on antibiotics and taken to the operating room for emergent incision and drainage (I&D) of left sided multi space infection via intra and extra oral approaches with placement of Penrose drains and extraction of multiple teeth. As per the anesthesia team, the patient was to remain intubated at the end of the procedure and was transferred to post anesthesia care unit (PACU) sedated and in stable condition. She was extubated without complication and continued to receive antibiotics and pain medication and when stable was discharged.

According to Milliman Care Guidelines (MCG) General recovery care 26th edition Head and Neck Surgery or procedure, the operative status criteria is ambulatory for most eye, middle ear, inner ear, or nose surgeries; some pharyngeal airway procedures for sleep apnea; most biopsy procedures; most simple drainage procedures without drain in place; most major dental procedures; operations for hearing loss; cleft palate or lip operations; most vocal cord operations; many cyst or sinus remnant operations; epistaxis control with ALL of the following: no posterior packing, no procedures endangering airway, tonsillectomy or adenoidectomy (or both) without complication (e.g. ["for example"], hemorrhage). In addition, MCG notes that discharge criteria include continued inpatient stay is needed until 1 or more of the following are present: acceptable patient status for next level of care is achieved; ALL of the following are present: operative site and other wounds acceptable, pain and nausea absent or adequately managed, temperature status acceptable, no infection, or status acceptable, ocular status acceptable, orbital edema or inflammation absent or controlled, airway and swallowing status acceptable, activity level acceptable, intake acceptable, no inpatient interventions needed, general discharge criteria met. The patient required inpatient admission. She needed to be intubated and kept intubated until she could be safely extubated and then monitored given the intra and extraoral drains. It was appropriate for this patient to be admitted. Thus, inpatient admission was needed because of the need for a surgical procedure that necessitated drainage and airway protection.

The admission was justified at the inpatient admission level, as the patient could not have been managed in an ambulatory/observation setting. 

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.