Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Defective oral hardware.
Issue under review: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the inpatient admission was not medically necessary.

This is a who presented to the ER for admission to the oral surgery service for removal of defective hardware that was placed in the previous year. The patient had left facial swelling from an incision and drainage (I&D) that was performed in the ER and was placed on antibiotics. 

The day of admission, the patient was afebrile. The computed tomography (CT) showed no airway encroachment. The patient was taken to the OR where the hardware was found to be loose. This was removed along with tooth #17 and the patient had an uneventful night and was discharged the following day. 

The admission was denied and the hospital is appealing and states that a stay of over two midnights is a requirement for admission and the Milliman Care Guidelines (MCG) for admission were met.

The patient had no preoperative condition that wanted an overnight stay nor was there a perioperative event that warranted and inpatient stay. There was no reason for the patient to spend the night in the hospital and the hospital only quotes the guidelines but does not say what was met.

Admission is indicated for a head and neck procedure and one or more of the following:
1)	Hemodynamic instability
2)	Hypertension requiring inpatient treatment
3)	Acute cardiac or peripheral ischemia
4)	Cardiac arrhythmias
5)	Severe heart failure
6)	Respiratory abnormalities
7)	Severe airflow or ventilation abnormalities
8)	Impending or actual respiratory arrest. 
9)	Neurologic abnormalities, including 1 or more of the following:
10)	Uncontrolled seizures
11)	New-onset severe neurologic findings requiring inpatient care
12)	Suspected acute intra-abdominal process with peritoneal signs
13)	Severe physiologic disorder remaining after emergency or observation level care
14)	Abdominal abnormalities
15)	Acute renal failure
16)	Significant uremic complications
17)	High fever
18)	Severe nutritional abnormalities
19)	Severe electrolyte abnormalities
20)	Acute blood loss
21)	Severe anemia
22)	High-risk low platelet count
23)	Disseminated intravascular coagulation
24)	Severe adverse drug or systemic toxin reaction
25)	Severe pain requiring acute inpatient management
26)	Severe behavioral health issues

Inpatient monitoring needed; examples include:
1)	Vital signs, neurologic signs, or vascular checks more frequently than every four hours
2)	Cardiac or respiratory monitoring beyond scope (eg, over 24 hours) of observation care
3)	Pulmonary artery catheter monitoring
4)	Suspected compartment syndrome
5)	Cerebral bleeding, hydrocephalus, or vasospasm monitoring
6)	Increased intracranial pressure or cerebral edema monitoring
7)	Fetal monitoring

Treatment requiring inpatient care; examples include:
1)	IV fluid to replace significant ongoing losses (greater than three liters per meter squared [3L/m2] per day)
2)	High-concentration oxygen (greater than 40%)
3)	Frequent respiratory therapy (more frequently than every four hours) to maintain airflow rates greater than 60% of baseline
4)	Epidural analgesia
5)	IV anticoagulation, vasoactive medication, or antiarrhythmic medication
6)	Acute thrombolytics (generally require 24 hours of observation)
7)	Antidote administration
8)	Emergency procedures needed

According to the MCG guidelines, an admission is indicated for a head and neck surgery procedure if one of the General Admission Criteria are met. The patient had a head and neck procedure but there is no documentation of a significant medical problem or any of the above problems; therefore, the appropriate status would be a lower level of care, such as observational status.