Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Submandibular Gland swelling
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a female who presented to the emergency department with left neck swelling. She was well until a week prior to presentation when she developed a sore throat. The day prior to presentation she noted swelling on the left side of her neck. She also found it to be painful to swallow and had decreased oral intake. They had noted a 'stone' in the back of her throat about a week prior. The swelling worsened, and therefore she was brought to the emergency department for evaluation. Her past history was significant for depression and a history of a renal cyst with one functioning kidney.

Her physical examination was significant for left sided neck swelling with induration on palpation of the left submandibular gland, and mildly inflamed tonsils. The laboratory values were obtained as well as a computed tomography (CT) scan of the neck. Her C-reactive protein (CRP) was 7.7. The CT scan revealed inflammatory changes of the left submandibular gland with associated soft tissue edema and a few enlarged lymph nodes adjacent to the left submandibular gland, as well as mucosal thickening of the left maxillary sinus. She was diagnosed with sialadenitis of the left submandibular gland, and the oral maxillofacial team recommended hospital admission for intravenous antibiotics and fluids.

In the hospital, she was treated with intravenous Clindamycin and cultures were sent. She was also placed on intravenous fluids. She was followed by the oral maxillofacial surgical team. By the third hospital day her antibiotics were switched to intravenous Zosyn. The swelling improved with treatment, and she was afebrile and was tolerating fluids well. She was felt to be stable for discharge to home with continued treatment and follow up as an outpatient. She was also cleared for discharge by social work due to her history of depression.

The health plan, in its determination of medical necessity, has not acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of an inpatient hospital admission was medically necessary for this patient. The patient presented with neck swelling, pain, and difficulty swallowing and was found to have sialadenitis. She was appropriately evaluated in the emergency department and was felt by the specialist providers to require intravenous antibiotics. She also had a decreased oral intake and required intravenous fluids to maintain her hydration status. This was particularly important for this patient, since she had decreased oral intake and  had one functioning kidney; therefore, the remaining kidney needed to be protected.

The decision making at the time of admission for this patient was consistent with her age, the presence of sialadenitis that required parenteral antibiotics for treatment, and the need for intravenous fluids to maintain her hydration status and protect her kidney. She required parenteral antibiotics, intravenous fluids, and specialist consultation along with close monitoring, which requires an inpatient level care. 

The health plan's determination of medical necessity is overturned in whole.