Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower lip swelling.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male teen with medical history significant for autism that was taken to the ED (emergency department) by his parents because of one-day history of lower lip swelling that was getting worse over the course of the day. Ice was not helpful. There was no history of anaphylaxis or allergy, trauma, or bites to the area. He had no reported fevers or change in appetite. 
Vital signs included temperature 37.4, heart rate 109, respiratory rate 18, and blood pressure 118/77. Examination was significant for non-toxic appearance, in no acute distress, with lower lip swelling, pustule at the bottom of the lower lip, tenderness on the lip and submental area, clear lungs, and baseline neurologic exam. He was initially diagnosed with angioedema and treated with Decadron, diphenhydramine, famotidine, and IM (Intramuscular) epinephrine. With no improvement, infection was suspected, and laboratory evaluation ensued, significant for leukocytosis (white blood cell 19.7K), left shift (80.7%), and elevated C-reactive protein (4.7). He was treated with clindamycin and a dental consult was obtained. CT(computerized tomography) of the maxillofacial area with contrast was recommended followed by admission to the pediatric ward. The CT(computerized tomography) scan obtained  revealed a fluid collection in the lower lip region (1.0x3.4x0.9cm) suspicious for abscess as well as submental adenopathy. Admission orders included half-maintenance IV(Intravenous) fluids, regular diet, parenteral clindamycin, Tylenol and Motrin as needed, OMFS (Oral and Maxillofacial Surgery) and ID (infectious disease) consultations, and Covid-19(Coronavirus disease) testing. Under local anesthesia, the abscess was drained, and wound culture sent. He was unable to tolerate the recommended post-procedure packing of the wound. He was started on a liquid and pureed diet which he tolerated. The following day, the swelling had improved and there was no active bleeding or discharge. His diet was advanced to regular. He was subsequently deemed stable for discharge to complete a course of cephalexin.

No, acute inpatient admission was not medically necessary.
Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient.

This male teen presented to the ED (emergency department) with rapidly progressive swelling of his lower lip initially concerning for angioedema secondary to anaphylaxis. When standard management of anaphylaxis did not yield improvement, infection was considered. CT (computerized tomography) scan documented presence of an abscess. Cultures ultimately revealed infection with MRSA (methicillin-resistant Staphylococcus aureus). He was treated with clindamycin and the abscess was drained at the bedside under local anesthesia. He did well and was able to discharge home the following day. At no time did he exhibit signs or symptoms or respiratory distress or increased work of breathing. He was not always cooperative due to his diagnosis of autism and concurrent developmental delay, but he was otherwise hemodynamically stable with no evidence of impending sepsis. While it was reasonable to initiate treatment with parenteral antibiotics in the ED (emergency department) and transition appropriately to enteral antibiotics, he did not require acute inpatient management. He could have been safely and appropriately managed at lower of care.