Diagnosis: facial cellulitis secondary to odontogenic infection

Treatment inpatient stay

The insurer denied coverage for inpatient stay

The denial is upheld

The patient is a male with past medical history significant for pre-diabetes and rheumatoid arthritis who presented to the Emergency Department (ED) with complaints of pain and swelling to right side of his face. Vitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 167/76, Pulse 66, Respiratory Rate 18, oxygen (O2) saturation 95% [percent] on Room Air. Laboratory values were notable for the following: white blood cell count (WBC)-9.6, hemoglobin (Hgb)-13.4, hematocrit (Hct)-39.2, glucose-104, creatinine-0.78. The patient was empirically started on intravenous (IV) antibiotics (Unasyn) for facial cellulitis secondary to odontogenic infection. Maxillofacial computed tomography (CT) scan showed a periapical abscess of the right second premolar and diffuse soft tissue stranding to right side of face with lymphadenopathy. Patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics and follow-up with oral maxillofacial surgery (OMFS) as an outpatient.

According to the documentation, the patient presented with right side facial swelling secondary to dental abscess. Otherwise, he was afebrile, stable hemodynamically with normal WBC. No surgical intervention was required. Based on above findings, the patient met criteria for observation level of management. The documentation does not support need for acute inpatient hospitalization.

The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

The insurer's denial of coverage for the inpatient stay is upheld. Medical necessity is not substantiated.