Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Odontogenic infection
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult female with past medical history of breast cancer (metastatic). She presented with three weeks of left jaw pain. She had symptoms of pain and swelling for approximately 3 three weeks prior to the ED (emergency department) visit. The patient's symptoms had progressed for one to two days of jaw swelling, and had markedly worsened, prompting her to go to an ENT (otolaryngology) doctor. ENT (otolaryngology) sent the patient to the ED (emergency department) for evaluation and to rule out Ludwig's angina. The patient was admitted to the ED (emergency department) at about 1500 hours. A CT (computed tomography) scan was done, and it showed a fluid collection at the base of the tongue secondary to an odontogenic infection. The ENT (otolaryngology) consult recommended that the patient be seen by OMFS (oral and maxillofacial surgery), who saw the patient in the ED (emergency department) late in the evening.
The patient was started on IV (intravenous) Unasyn and was admitted to inpatient. She was kept NPO (nothing by mouth) until an OR (operating room) could be scheduled, and this was done on the morning of the next day.  The patient had an incision and drainage with drain placement and removal of tooth #18 done. The patient went from the OR (operating room) to the PACU (post anesthesia care unit) and then to the floor on that afternoon. She continued to receive IV (intravenous) antibiotics. Post surgery, she had some hypertensive episodes and labetalol was ordered. Her BP (blood pressure) stabilized on that evening, and she was discharged the following day. She received IV (intravenous) antibiotics until discharge. The health plan denied coverage of the inpatient admission as not medically necessary. The denial is being appealed.

The Inpatient Hospital Admission was medically necessary. 

The patient needed both IV (intravenous) antibiotics and surgical anesthesia. The patient was admitted early in the morning of the day of surgery and surgery was performed later that morning. There is nothing in the records to indicate that surgery could have been done any earlier that morning. The patient was discharged within 23 hours of her surgery. It is undeniable that the patient needed both IV (intravenous) antibiotics and surgical intervention. The patient was deemed to be an ASA (American Society of Anesthesiologists) III risk for general anesthesia due to her past medical history. It was necessary for the patient to be NPO (nothing by mouth) for her surgery. The patient went to surgery as soon as reasonably possible and was discharged within 23 hours of her surgical procedure. The inpatient admission was medically necessary due to the necessity of the IV (intravenous) antibiotics and surgery.

The Inpatient Hospital Admission was medically necessary. 

The patient needed both IV (intravenous) antibiotics and surgical anesthesia. The patient was admitted early in the morning of 11/16/2022 and surgery was performed later that morning. There is nothing in the records to indicate that surgery could have been done any earlier that morning. The patient was discharged within 23 hours of her surgery. The patient needed both IV intravenous) antibiotics and surgical intervention. The patient was deemed to be an ASA (American Society of Anesthesiologists) III risk for general anesthesia due to her past medical history. It was necessary for the patient to be NPO (nothing by mouth) for her surgery. The patient went to surgery as soon as reasonably possible and was discharged within 23 hours of her surgical procedure. The inpatient admission was medically necessary due to the necessity of the IV (intravenous) antibiotics and surgery.