Diagnosis: Mouth and Neck Pain.
Treatment: Inpatient Admission.

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

The patient is a male. He presented to the ED (emergency department) with a 3 day history of floor of mouth and neck pain with trismus and dysphagia. There was decreased oral intake.

The patient's temperature was 101.2. ENT (otolaryngology) exam reported pharyngeal edema and erythema with FOM (floor of mouth) induration. WBC (white blood count) was 20.3. CT (computed tomography) reported a left floor of mouth located abscess. Flexible laryngoscopy noted edema on the lingual surface of the epiglottis. There was no sign of airway obstruction.

The patient was started on IV (intravenous) antibiotics, steroids and pain medication. Inpatient admission was initiated. The patient was taken to the OR (operating room) for I&D (incision and drainage) of the abscess and extraction of tooth #17. He was discharged.

The inpatient admission was previously denied coverage by the health plan as not medically necessary, and the denial is being appealed.

No, the Inpatient admission was not medically necessary.

All records were reviewed. The patient presented with a floor of mouth loculated abscess, leukocytosis and elevated temperature. There were no complaints of airway distress. An I&D (incision and drainage) was performed. The patient improved after the I&D (incision and drainage). The patient's pain was controlled. There were no intraoperative or postop complications. The patient was discharged. Based on the above, the medical necessity of the inpatient admission cannot be confirmed, as the patient's care could have been provided at an Observation level of care.

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

The inpatient admission was not medically necessary.