Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Infection; Cellulitis

Treatment: Inpatient admission

The insurer denied the inpatient admission. The denial was reversed.   

This is a young male patient who presented to the hospital with right sided facial swelling, erythema extending toward the right eye.  It was reported that the patient had been to the hospital the day prior to presentation with similar symptoms and was discharged home on amoxicillin. Laboratory work up and blood cultures were obtained. The patient's C-reactive protein (CRP) was elevated at 5.3 mg/dl. He was transferred to another medical facility for further treatment. Upon initial examination it was noted that the patient had right facial swelling and tenderness under the cheekbone/right maxillary area as well as close to the right eye.  In addition, the patient's uvula was noted to be deviated to the left. The oral amoxicillin was discontinued and he was started in intravenous (IV) clindamycin. It was determined that a dental infection was the likely source of the infection. His symptoms improved and he was discharged home on a 10 day course of oral clindamycin.  

According to the American Association of Oral and Maxillofacial Surgeons (AAOMS), "Untreated odontogenic infections can lead to pain, abscess, cellulitis, and difficulty eating or drinking.  In these children, dehydration is a significant consideration; [and the] prompt treatment of the source of infection is imperative...Infections of odontogenic origin with systemic manifestations [e.g., elevated temperature (102 to 104 degrees Fahrenheit), facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea] require antibiotic therapy.  Severe but rare complications of odontogenic infections include cavernous sinus thrombosis and Ludwig's angina.3,13  These conditions can be life threatening and may require immediate hospitalization with intravenous antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon.3,13" (AAOMS 2015).

As per Erazo & Whetstone (2019), "Antibiotic therapy for dental infections is necessary for systemic symptoms, fascial space infections, and infections that spread to the bony cortex and surrounding soft tissue." And though amoxicillin is most commonly prescribed for dental infections, due to the high antibacterial resistance, broad spectrum and intravenous antibiotics must be considered for those who are not responsive to oral therapy. Weise et al (2019) article states that the "majority of head and neck infections are odontogenic [17]. Odontogenic infections can spread and cause severe complications, e.g. compromised airways, sepsis, tissue necrosis, endocarditis, mediastinitis and deep neck infections [3]", and that these "severe odontogenic infections can be potentially life-threatening [14, 17]".   

Based on the review of the medical record, this patient's facial cellulitis did not respond to outpatient management. Despite taking oral amoxicillin, the patient's infection progressed. By the time the patient was received the patient's facial cellulitis was spreading towards his right eye, and the infection was causing pharyngeal swelling that caused deviation to his uvula. It was noted that the patient's clinical symptoms improved after the patient was switched to intravenous clindamycin. The patient's clinical presentation on admission necessitated close inpatient monitoring and aggressive antibiotic treatment. The patient's facial cellulitis had progressed to the point at which the patient was at risk for ocular involvement and airway compromise. Thus, inpatient admission was medically necessary to treat this patient's medical condition. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.                                                

The carrier's denial of coverage for the inpatient hospital services is reversed.  The medical necessity is substantiated.