Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial swelling; headaches
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She has a past medical history significant for diabetes mellitus and hypertension. She presented with complaints of right-side facial swelling x 1 day. She also reported headache for two days. The patient took Tylenol at home. The patient denied fever, chills, dental pain, and problem with breathing or swallowing. The patient's vitals on presentation were BP (blood pressure) 130/74, P (pulse) 85, R (respiration) 18, T (temperature) 98.2, and Pulse oximetry 98% (percent). The patient's labs showed WBC (white blood count) 11.2, lactic acid 0.9, and Platelets 267. The patient was started on IV (intravenous) fluid and IV (intravenous) antibiotics. CT (computed tomography) scan of the patient's face was obtained. Consultation was requested from neurosurgery and oral surgery. CT (computed tomography) of the patient's facial bones showed Periapical abscess at the right maxilla with right maxillary odontogenic sinusitis, codical breakthrough to the anterior surface of the maxilla, buccal inflammatory changes, and possible trace/developing subperiosteal abscess. Right anterior and middle cranial fossa extra-axial collection incompletely evaluated. Differential includes a large arachnoid cyst with mild mass elect versus sequela of injury/insult. CT (computed tomography) of the patient's brain reported possibility of large arachnoid cyst. No intracranial bleed was noted. Large fluid density occupying most of right middle cranial fossa and portions of frontal lobe was noted. The patient was evaluated by neurosurgery and advised no neurosurgical intervention. They signed off on the case and advised follow up on outpatient basis.
Oral surgery evaluation was completed. They advised to continue antibiotics and warm compress to right cheek. They cleared patient from oral surgery perspective with continued improvement from IV (intravenous) antibiotics. The patient was admitted to inpatient hospital stay for further treatment, and she improved.

The Inpatient admission was not medically necessary.

The patient presented with right-sided facial swelling and was found to have right maxillary periapical abscess and odontogenic sinusitis. The patient was afebrile on presentation and did not have any findings to indicate sepsis or intracranial involvement due to the abscess. The patient was awake and alert and without any change in mental status. The patient was evaluated by neurosurgery and oral surgery and did not advise any surgical intervention. The patient had improved on IV (intravenous) antibiotics in the first 24 to 36 hours after presentation and did not show any findings to indicate progressive infection or sepsis. The patient did not have any findings to indicate need for inpatient admission and continued inpatient stay. Additionally, the patient was not Immunocompromised, the area of involvement in this case was not located over a prosthesis or implanted device and the patient did not have involvement of the eye (orbit). The patient was not in acute distress and in view of these facts of the patient's clinical status, ongoing risk of deterioration was low since diagnosis had been established and the patient was responding appropriately to the treatment. The patient did not have any acute complications during this time. No high frequency, high complexity, or high-risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates. In view of these findings and generally in accordance with guidelines, the ongoing inpatient level of care for the above duration was not medically necessary.