Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Open lock and dental abscess status-post incision & drainage
Treatment: Inpatient emergency admission
The insurer denied coverage for: Inpatient emergency admission.
The denial is: Upheld.
This adult patient who was transported to the emergency department (ED) with open lock and dental abscess. The patient was immediately treated with sedation and reduction of the subluxed mandible. The white blood count (WBC) is 5.6k. The patient was then admitted by the Oral and maxillofacial surgeons (OMS) who treated the patient. The admitting diagnoses include impacted teeth, cyst of mandible, and abscesses of mandible. The patient was treated and this included incision and drainage of infection, cyst removal, and removal of teeth including impacted teeth 32 and 31.

The patient had lock jaw that required treatment which was provided in the ED. There was also an infection which was treated in the operating room (OR). However, in order for inpatient care to be medically necessary there needs to be evidence of a severe infection. In this case, the cyst and teeth can be removed in the outpatient setting. The WBC is 5.6k which is normal. The other labs show inflammation which can be present for a number of reasons and none support severe systemic infection. 

Neal, T. W., & Schlieve, T. (2022), "Severe odontogenic infections are routinely treated with little associated morbidity and mortality. Improvements in surgical techniques, antibiotic treatments, and imaging modalities have made associated complications exceedingly rare. A number of complications have been described in the literature including airway obstruction, descending necrotizing mediastinitis, orbital abscess, septic cavernous sinus thrombosis, cerebral abscess, sepsis, necrotizing fasciitis, and Lemierre's syndrome. The purpose of this article is to discuss the pathophysiology of severe odontogenic infections and the risk factors associated with the development of complications. Given the morbidity and mortality of these conditions, it is important to review the clinical features of each and the diagnostic tools that aid in early recognition."

Fu, B., McGowan, K., Sun, H., & Batstone, M. (2018), "The rate of Intensive Care Unit (ICU) admission increased significantly from 7 to 24% during the decade (2 = 12.74; P = .000), although the clinical presentation of patients admitted to the ICU was similar in both cohorts. The mean number of days spent in the ICU increased significantly from 1.7  0.5 to 3.24  2.5 days (t = -3.63; P = .001), and the overall length of stay increased from 1.7  0.5 to 3.5  4.1 days (t = 2.99; P = .004). The use of preoperative computed tomography (CT) increased significantly from 42.9 to 93.3% (2 = 13.25; P = .000). The most significant predictors of ICU admission were lower third molar involvement (P = .026), dysphagia (P = .020), and C-reactive protein (CRP) levels exceeding 150 mg/L (P = .039).... Conclusions: The use of the ICU in the management of odontogenic infection has increased significantly at the Royal Brisbane and Women's Hospital over 1 decade. The demographic data and clinical presentation of the patients admitted to the ICU did not change significantly. However, the length of ICU stay and the total length of stay have both increased. A significant increase in CT usage for odontogenic infections also occurred. Third molar infections, dysphagia, and elevated CRP might be relevant clinical predictors of a more complicated course of care requiring ICU admission. More judicious use of CT scanning, combined with prompt surgical consultation and intervention, might reduce the rate of ICU admissions for odontogenic infections." 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient emergency admission is not substantiated.