Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oral/mandibular abscess.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of breast cancer status/post (s/p) right lumpectomy, hypothyroidism, on Tamoxifen and Synthroid, who presented to the emergency department (ED) with complaints of (c/o) left lower jaw/dental (molar) pain, swelling, and difficulty swallowing. The pain was not relieved by Motrin. She saw an emergency dentist who started her on oral Augmentin. Her breathing was noted as even, unlabored, with a normal oral mucosa, no oropharyngeal exudate, uvula midline, left lower gum tenderness, left lower jaw swelling and redness, normal phonation, no drooling or stridor. The exam revealed tenderness of the lower gums and left lower jaw erythema and induration. Lab results showed the white blood cell count (WBC) 9.2. A computed tomography (CT) scan of the neck with contrast showed soft tissue swelling and subcutaneous stranding adjacent to the left (L) mandible but no definite abscess collection, trachea midline and patent, parotid and submandibular glands symmetric. A chest x-ray (CXR) showed left basilar atelectasis and/or infiltrate. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with nonspecific T wave changes.

She was started on Zosyn and Vancomycin, Toradol for pain, and then seen by oral and maxillofacial surgery. She was admitted with a diagnosis of oral/mandibular abscess and taken to operating room (OR) for incision and drainage (I&D). She was found to have a vestibular and buccal space abscess, also drainage of purulent material from the gingival margin. Tooth number (#) 19 was removed along with an associated cyst. She was also seen by infectious disease and advised to continued intravenous (IV) antibiotics.
Infectious disease (ID) follow-up noted decreased tenderness and induration of the left cheek and submental, and stated from an ID standpoint, the patient was cleared for discharge on by mouth (PO) Augmentin. At issue is the medical necessity of an inpatient stay.
 
The inpatient stay was not medically necessary for this patient. She could have been safely and appropriately managed at a lower level of care.

This patient presented with lower jaw and dental pain and was found to have a vestibular abscess at molar number (#) 19. She was afebrile with normal vital signs and remained stable and afebrile throughout her course. Her presentation and history would raise concerns for deep neck space infection and possibly Ludwig's Angina. However, she was noted to have normal phonation, unlabored breathing, no drooling, no stridor, and normal breath sounds on exam. She was also fully worked up in the emergency department (ED), had a computed tomography (CT) scan of the neck with contrast which showed the trachea to be midline and patent. There were no findings of impending airway obstruction. There were no findings of deep neck space infection. She did require initial intravenous (IV) antibiotics and underwent I&D of the vestibular abscess though no drain was kept in place, and she had steady clinical improvement.
She did not have bacteremia, she did not have signs/symptoms of a systemic infection, her infection was localized, and she did well with antibiotics and drainage of the collection. She was medically stable for discharge on oral antibiotics.