Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Submandibular sialolithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient presented to the hospital for right-sided jaw swelling that began the previous evening.  The patient had a history of diabetes mellitus, hypertension, and sialolithiasis.  The patient had spontaneously passed two stones the previous year following Ear, Nose, and Throat (ENT) consultation. The patient had been seen in the emergency department 2 days prior for symptomatic hyperglycemia and was discharged home.  The review of systems was positive for blurry vision 2 days prior, right-sided jaw and mouth pain, right facial swelling, recurrent right-sided salivary stones, and foul taste in mouth.  The patient's vital signs were documented as blood pressure of 164/89, temperature of 99.5 Fahrenheit, pulse of 89, respirations of 17, and oxygen saturation of 99% on room air.  On exam, sialolith was palpable on the right.  Purulence was expressed upon intra and extraoral palpation.  Laboratory results noted white blood cell count of 13.1 and glucose of 352.  Radiographs of the chest were unremarkable.  A computed tomography (CT) of the soft tissue of the neck noted 1 centimeter (cm) obstructing stone within the distal right Wharton duct that resulted in 10 millimeter (mm) dilatation of the duct as well as right submandibular gland ductal dilatation.  The patient was assessed with acute infected right submandibular sialolithiasis.  The patient was currently hypertensive and hyperglycemic.  Blood pressure readings noted 190/120 and 174/109.  Initial treatment included intravenous antibiotics, intravenous fluid, intravenous Toradol, and intravenous morphine.  The patient would require medical optimization prior to urgent surgical intervention.  There was a plan to admit to oral surgery service with surgery planned for the following day.  It was noted that the patient had been recommended for low-dose sliding scale insulin.  The patient's blood pressure was 129/79 with a temperature of 98 Fahrenheit.  There was a plan for excision of right submandibular stone and drainage of associated abscess.  However, the patient spontaneously passed the stone overnight.  There was no further purulence draining from the affected duct.  The patient was discharged home with oral antibiotics.  The patient would benefit from excision of right submandibular gland due to recurrent infections which would be plan for future outpatient procedure.

Per the cited references, full inpatient admission for sialadenitis is recommended when there is hemodynamic instability that is not readily corrected by appropriate treatment, for complications such as extension of infection into the deep spaces of the neck, Lemierre syndrome, respiratory obstruction, when surgical drainage is needed that cannot be performed in observation care, or when there is inability to tolerate oral intake.  In this case, the patient presented to the hospital with recurrent sialolithiasis with obstruction.  The patient was assessed with acute infected right submandibular sialolithiasis.  The patient was hypertensive and hyperglycemic.  There was a plan for excision of right submandibular stone and drainage of associated abscess.  The patient was recommended for surgical drainage.  The patient required optimization in the inpatient setting.  There was severe infection and need for normalization of uncontrolled blood pressure and diabetes.  The planned surgery could not be completed in observation level of care due to the need for optimization that required inpatient monitoring and treatment.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a full hospital admission is substantiated.