Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, Sepsis, Difficulty Swallowing s/p Recent Tonsillectomy.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female who was admitted with a complaint of throat pain post-tonsillectomy six days before this presentation. She reported an associated fever and a foul taste in her mouth. She has difficulty with pain during swallowing and a poor appetite. On assessment, she had a maximum temperature of 38.1 degrees Celsius, heart rate of 84, and a blood pressure of 128/91. The examination of the mouth showed erythema to the posterior pharynx and uvula, with purulent yellow-green collections lateral to the uvula on both sides and a foul odor. The cardiopulmonary examination was unremarkable.
The laboratory studies showed leukocytosis of 17.1. A wound culture was obtained in the emergency department (ED) from the pharynx. She was admitted to the hospital for treatment of a postoperative infection. The ED started Ceftriaxone; however, the medical team changed the treatment to Cefepime and Vancomycin. The ear, nose, and throat (ENT) specialist was consulted to evaluate, and a computed tomography (CT) scan of the neck was ordered. The patient was reassessed later in the day and reportedly improved. The Vancomycin was discontinued, the white blood cell count improved to 15, and the cultures remained negative.

The ENT specialist did not assess the patient until 24 hours later. By this time, the CT scan of the neck showed no evidence of an abscess. The blood cultures were still negative, and she tolerated a clear liquid diet. The ENT specialist suspected a post inflammatory response from surgery and dehydration and cleared the patient for discharge home on Prednisone, anti-inflammatory medications, and oral liquid narcotics. The patient was discharged later that afternoon.

Yes, in its determination of medical necessity, the health plan acted reasonably, with sound medical judgment, and in the patient's best interest. The inpatient hospitalization is not warranted in this case.

The requested health service/treatment of an inpatient hospital admission was not medically necessary. The patient was admitted six days post tonsillectomy with a painful throat and systemic inflammatory response syndrome (SIRS). She was admitted to the hospital to rule out sepsis and abscess formation. This was ruled out with a CT scan of the neck. There was a slight delay in obtaining an ENT consultation; after the examination, it was noted that the patient was experiencing expected post inflammatory syndrome and not an acute infection. Therefore, there was no need for ongoing antibiotic treatment, and the patient was treated with anti-inflammatories. She was subsequently discharged home, tolerating a diet with an improvement in her pain.

In the absence of severe postoperative infection, clinical criteria for inpatient admission are not satisfied. It is often difficult to distinguish between true sepsis and SIRS criteria secondary to inflammatory responses in the body; therefore, it was reasonable to admit the patient under an alternate level of care for close monitoring.

The health plan's determination of medical necessity is upheld in whole.