Diagnosis: Orofacial odontogenic infection
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed.

The patient was then male child who presented to the Emergency Department (ED) on with complaints of tooth pain and cheek swelling a day after a few days dental extractions. The patient's vital signs were stable, but his lab work was significant for an elevated white blood cell count of 15.2. On exam, there was right cheek swelling with redness and tenderness to palpation extending to the eye. The patient had clinical findings consistent with an orofacial odontogenic infection. This kind of an infection may not present with fever or signs of sepsis.

Because the patient had a 1-day history of progressively worsening facial swelling, inpatient treatment with antibiotics, until improvement in swelling, was the most appropriate management option. Literature indicates that most severe orofacial infections develop from periapical or periodontal infection and spread occurs along the anatomic pathways of least resistance, including to the soft tissues of the buccal area or into the maxillary sinus, palate, lingular, or adjacent soft tissues spaces, if spontaneous intraoral drainage does not occur.

In this patient's case, Dentistry decided he needed extraction of additional teeth, which they performed and returned the patient to the ED. This procedure entails a small risk of further local spread of infection and hematogenous dissemination (bacteremia) which can seed native or prosthetic heart valves, or joints. Studies show that bacteremia in patients with dental caries and periodontal disease tends to be more frequent and sustained. Orofacial odontogenic infections that spread beyond the teeth and alveolar processes are polymicrobial, yielding an average of four to six isolates that are mostly anaerobes. Moreover, the patient vomited twice while awaiting the ambulance ride back to the ED.

Based on the review of the medical record and literature, inpatient admission was medically necessary to closely monitor and treat this patient's infection.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The carrier's denial of coverage for the acute inpatient stay (inpatient admission) from should be reversed. The medical necessity is substantiated.