Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient is a female with Hashimoto's thyroiditis, atrophic gastritis who presented to emergency department (ED) with 3 days of swelling of neck and cheeks. She reported being in a hot tub, then had swelling and redness around her lips on the Left (L) side, it spread to the L side of her face, then spread to the submandibular region, on the right (R) side of her neck and cheek. She reported having fevers and some difficulty swallowing. Her vital signs (VS) in the ED were, temperature 37.5, pulse 85, blood pressure (BP) 165/99, respiratory rate (RR) 20 and her room air (RA) saturation was 98 percent (%). Her lactate was 1, she had a normal white blood cell count (WBC) of 8.6, normal differential, and normal basic metabolic panel (BMP).
She was noted to appear well-developed, well-nourished (WDWN), alert and oriented. She was noted to have no drooling, no stridor, no trismus, but had submandibular, L submental swelling, and swelling of cheeks. She was noted to have facial edema and gingival inflammation and also noted to have L upper lip vesicular rash. The computed tomography (CT) showed soft tissue swelling of mandible. The plan was admission with antibiotics and consult oral and maxillofacial surgery (OMFS). She was started on Zosyn and Vancomycin with indication of Skin/soft tissue infection, consider cellulitis, abscess and Ludwig's Angina. Antibiotics were changed to Unasyn.
 
She was seen by infectious disease (ID) and noted the patient to have no throat pain and no dysphagia, advised Unasyn and Vancomycin, she was also treated with intravenous (IV) Acyclovir for the rash that stated as appearing vesicular, possible herpes simplex virus (HSV), with plan to change to by mouth (PO) Valtrex after 3 days IV.
She was seen same day by OMFS, who found the patient to have gingival inflammation, noted imaging without signs of Ludwig's Angina, and advised the patient would need comprehensive dental evaluation dental extractions, and recommended oral Augmentin times one week and Peridex.
She was brought to dental clinic for extraction of non-restorable teeth after bridge sectioning. It was advised to continue Unasyn while in hospital and then discharge on oral Augmentin. She responded well to antibiotics, improved, and was discharged.
 
The patient was admitted with facial swelling associated with gingival inflammation and dental problems, however, she did not have difficulty breathing, she did not have stridor or drooling, she did not have any signs of airway compromise, and she was seen on day of admission by OMFS who reviewed her CT scan and concluded there were no concerns this patient had Ludwig's Angina. She was advised to see dental for extractions which were performed. She was treated with antibiotics though she was afebrile and hemodynamically stable from time of ED presentation and throughout admission, with normal WBC and diff. She was also given an antiviral (IV Acyclovir) to cover for possible HSV rash.
She had normal VS throughout, was afebrile, had no respiratory distress, no concern for Ludwig's Angina, and tolerated dental extraction without incident. She did not have uncontrolled pain, altered mental status, and did not have infection periorbital or overlying an implant or prosthetic material. There was no indication that patient had a necrotizing skin and soft tissue infections (SSTI), necrotizing fasciitis, and she responded well to dental extraction and antimicrobials. She did not have uncontrolled pain. She did not have periorbital cellulitis or infection overlying an implant. The patient could have been safely and appropriately treated at an alternate level of care (LOC) and then transitioned to outpatient with follow-up.