Appeal type: Medical necessity
Decision: Upheld

Vision
Inpatient Hospital

Diagnosis: Periorbital Cellulitis
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female that was referred to the emergency department (ED) with a two-day history of worsening right eye pain. She also reported discharge with crusting, decreased vision, and swelling. She denied trauma. Her vital signs included temperature 37, heart rate 86, respiratory rate 18, and blood pressure 100/75. The examination was significant for non-ill-appearing, rhinorrhea, moist mucous membranes, right eye discharge, intact extraocular movements, injected conjunctiva on the right with hemorrhage, right eyelid swelling with erythema, no proptosis, and non-focal neurologic examination. The laboratory evaluation was significant for white blood cell count (WBC) 7.9with 81 percent (%) neutrophils, C-reactive protein (CRP) 1.4, and negative rapid viral screen. A computed tomography (CT) was obtained revealing right pre-septal cellulitis without post-septal extension or bony erosion.
She was treated with Unasyn and was admitted for further management. Admission orders included continuation of Unasyn, Tylenol/Motrin as needed, regular diet, and routine vital signs. The following day, she was eating and drinking at baseline. The pain had improved overnight to 5 out of 10. Upon examination, the eyelid was still swollen, with injected conjunctiva and watering. The discharge had subsided and the blood culture was pending. She continued to receive Unasyn. The following day the swelling was significantly reduced but her eye was not yet back to baseline. She reported no pain. She had no fever. There was still some swelling on examination. She continued to receive Unasyn. The swelling had subsided, and her eye was very close to baseline in appearance. She had minimal tenderness on pressure with normal extraocular movements. She was deemed stable for discharge to complete a four-day course of Augmentin.

The inpatient hospital stay was not medically necessary. Periorbital, or preseptal, cellulitis is a type of facial cellulitis that involves infection or inflammation of the eyelid and the periorbital tissues without affecting of the orbit. Causes include bacteremia, sinusitis, trauma, wound infection, or abscess. Prior to the Haemophilus influenzae type b (HIB) vaccine, Haemophilus influenza type B was the most likely bacterial pathogen. Bacterial causes now include group A streptococcus, Staphylococcus aureus, and pneumococcus. In addition to cellulitis, evaluation reveals intact extraocular movements, intact pupillary function, and lack of proptosis. A CT scan reveals superficial inflammation anterior to the orbital septum. Treatment includes antibiotics and close monitoring for progression to orbital cellulitis. Orbital cellulitis involves infection or inflammation of the tissues of the orbit. Clinical findings include proptosis, limited extraocular movements, chemosis (edema of the conjunctiva), swelling of the eyelids, and altered visual acuity. Patients typically also have constitutional symptoms. Orbital cellulitis may involve direct extension from sinusitis, local infection, or bacteremia. The most common cause in children is sinusitis. Spreading infection may ultimately involve the venous system, bones, and central nervous system. Vision loss may result, as well as brain abscess. Organisms are similar to preseptal cellulitis. Treatment must be rapid and aggressive, with hospitalization and systemic antibiotics. A CT scan is essential to detect presence of abscess and/or intracranial extension. Drainage is ultimately necessary in the presence of abscess.
This patient presented to the ED with complaints suggestive of periorbital cellulitis. Her physical examination was consistent with periorbital cellulitis, and the CT scan substantiated a diagnosis of pre-septal cellulitis.