
202111-143265
2021
Fidelis Care New York
HMO
Infectious Disease
Inpatient Hospital
Medical necessity
Overturned
Case Summary
Diagnosis: Mastoiditis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.
The patient was admitted with complaints of left-sided jaw and neck pain after a dental procedure. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), no signs of lockjaw. Lab work was unremarkable. A computed tomography (CT) scan of the neck showed left cervical lymphadenopathy (LAD), and left-sided mastoiditis and otitis media, and suspected infiltrating neoplasm, a chest x-ray (CXR) showed no active chest disease. The patient was diagnosed with a nasopharyngeal mass and treated with intravenous (IV) antibiotics and pain control. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was medically necessary at an acute inpatient level of care.
This patient presented to the ED with left-sided jaw and neck pain after a dental procedure. The patient was subsequently found to have a nasopharyngeal mass, for which antibiotics were initiated and ear, nose, and throat (ENT) was consulted. The patient did not respond to a course of outpatient antibiotics, which is considered a failure, and it was recommended the patient receive IV antibiotics for the mastoiditis and otitis media. In addition, the nasopharyngeal mass is documented to have displaced the patient's airway to the right, which increases the clinical concern for acute respiratory failure, and the patient required close clinical monitoring for airway compromise and/or need for intubation, sepsis, and adequate oral intake, and this could not have been safely provided at an observation level of care. Overall, this patient's presentation and potential for decompensation meant that an inpatient level of care was medically necessary.