Diagnosis: Sore Throat and Fever.
Treatment: Inpatient Admission.

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of sore throat and fever.

The patient's pulse was 146. WBC (white blood count) was 8.7. The patient was treated with exudative tonsillitis and discharged on Augmentin.

The patient presented back with a fever of 102.9 with difficulty swallowing. CT (computed tomography) reported lymphadenopathy and retropharyngeal phlegmon vs abscess. Medical therapy included IV (intravenous) Zosyn and Decadron. The patient was transferred to the ICU (intensive care unit) for tachycardia and tachypnea. ENT (otolaryngology) evaluation did not recommend surgery. IV (intravenous) antibiotics were changed to IV (intravenous) Unasyn and Vancomycin. The patient improved and was sent home.

Coverage for the inpatient stay was previously denied by the health plan, and the provider is appealing the denial.

No, the Inpatient admission was not medically necessary.

All records were reviewed. The patient was seen in the ED (emergency department) for a second time after having been discharged from the ED (emergency department) with Augmentin for tonsillitis. The patient's throat symptoms had worsened. The patient had an elevated temperature on presentation with tachycardia. WBC (white blood count) was 8.7. CT (computed tomography) reported lymphadenopathy and retropharyngeal phlegmon vs abscess. ENT (otolaryngology) did not recommend surgical drainage. The patient was started on IV (intravenous) antibiotics and steroids.

There was no hemodynamic instability and no difficulty with the patient managing her own secretions. There was no oxygen desaturation, and the patient was started on a regular diet. Therefore, based on the information provided, the medical necessity of the inpatient stay cannot be confirmed, as the patient's care could have been rendered at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.