Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned. 

This is a female patient who presented to the Emergency Department (ED) with complaints of throat pain and swelling to the right lateral neck a couple of days prior to this ED presentation. The patient reported that she had taken a few doses of amoxicillin for several days that had been prescribed for another person. In the ED, the patient's white blood cell (WBC) count was 20.3 with neutrophil predominance.  A rapid strep test was performed with positive results.  On exam, the patient had visibly swollen lymph nodes on the right side and mild erythema in the oropharynx.  The patient was given oral Decadron for swelling and was treated with Toradol and intravenous clindamycin.  The patient was admitted for intravenous hydration and antibiotics. The patient's computed tomography (CT) scan of the neck revealed a right periauricular 4.3 x 1.7 cm collection reflecting abscess. The patient underwent a bedside aspiration resulting in 3 mL of purulent fluid. The patient's culture and sensitivity of the wound grow a few gram-positive cocci.   The patient's ultrasound of the neck  revealed a 4.3 x 1.7 collection within the right periauricular region with surrounding hyperemia, and multiple, mildly enlarged right-sided lymph nodes measuring up to 1.1 cm.  The patient underwent a repeat needle aspiration by the Ear, Nose and Throat (ENT) physician resulting in 1 cc of pus. The patient was discharged in stable condition.

The acute inpatient hospital services are considered medically necessary for this patient. When the patient was admitted to the hospital the patient clearly had a developing right neck abscess which had failed to improve with oral antibiotics.  The patient's abscess involved the right jugular lymph nodes (which are anatomically identified as the Deep Neck) into the periauricular spaces (upper neck, below the ear) as demonstrated on this patient's computed tomography (CT) scan and ultrasound.   It was judged that it was not drainable so an admission for IV antibiotics was medically necessary to observe for clinical improvement or progression. The right neck abscess had progressed to the point where it could be aspirated at the bedside by an ENT physician.  A follow up ultrasound of the neck showed that the patient's abscess had re-accumulated. ENT was consulted and a repeat bedside aspiration was performed. The patient continued to improve clinically after this with IV antibiotic treatment and was discharged. 

Considering that this patient had a deep space neck infection which required drainage multiple times during her inpatient stay, it is considered that this patient's care could not have been safely provided at a level of care lesser than inpatient admission. Thus, inpatient admission was medically necessary for this patient.
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for the acute inpatient hospital services is substantiated.  The insurer's denial should be overturned.