Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease - Bacterial Infection 
Treatment: Inpatient Hospital 

The insurer denied the inpatient hospital admission. The denial was overturned. 

The patient is a young female who had not received her scheduled vaccines at the time of service and presented to the ER with fevers and swelling of the left side of her face. One day before presentation she was seen in the emergency room, treated with intramuscular (IM) Ceftriaxone and sent home on Augmentin. Hours after returning home her mother noticed the swelling got progressively worse, fevers persistent and the patient became more fussy. 

They returned to the emergency room and upon arrival she was febrile to 102.9F, tachycardic to 163, had a respiratory rate of 46 and oxygen saturation of 98% on room air. The patient was observed to be breathing comfortably without any signs of distress. Laboratory studies in the emergency room were significant for leukocytosis of 21.6 with a C-reactive protein (CRP) elevated at 4.982, and erythrocyte sedimentation rate (ESR) of 25. She was negative for respiratory syncytial virus (RSV) and the flu. Blood cultures were drawn and patient was started on IV Unasyn. 

The ear, nose, and throat (ENT) team saw the patient, and observed no drainable abscess on laryngoscopy. A computed tomography (CT) scan of the neck under sedation was performed. The findings were suggestive of parotitis. There was no definite focal fluid collection to suggest abscess. Mumps IgM and IgG were sent for testing. The patient was then admitted to the floor for further management. After being admitted to the floor, infectious disease was consulted. 

By the second day of admission the swelling was noted to be slightly less erythematous. An ultrasound of the swelling was again performed, which indicated swelling but no abscess although it was a limited study. CBC and CRP were observed to be down trending. Mumps IgG and IgM resulted to be negative. Blood cultures were negative and up-to-date EBV studies resulted negative. Vancomycin was changed to Linezolid oral medication prior to discharge. The patient began having adequate oral intake and maintaining good urine in output. She was not having any signs of respiratory distress and the swelling was reducing in size. 

The requested health service of inpatient stay is medically necessary for this patient. Given her clinical presentation of rapidly enlarging parotid gland with persisting high temperatures (102.9 in ER) and elevated inflammatory markers, admission for IV antibiotics with close monitoring for response would be necessary. She was treated with IM Ceftriaxone the day prior. Invasive and/or resistant organisms would be of concern given her rapid worsening and progression. Given the location of her disease process, rapid progression may involve airway compromise via surrounding soft tissues of the neck. With such high inflammatory markers and elevated WBC, bacterial infection would be of significant concern. Even after admission she had increasing inflammatory markers for the first 2 days until it eventually began to normalize while on broad spectrum IV antibiotics. IV antibiotics with monitoring would be in the best interest of the patient. For these reasons, inpatient stay would be medically necessary.