Diagnosis: Left peritonsillar abscess with reactive left level II adenopathy

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned

This female patient presented with throat pain and received antibiotics in the emergency department and was discharged. She had severe pain 10/10 and difficulty swallowing. There was noted difficulty in speaking. She had a temperature 100.1oF (Fahrenheit) and pain on palpation of the swelling in the left neck. The computed tomography (CT) was obtained which showed: "Left peritonsillar abscess with reactive left level II adenopathy". She was admitted to the hospital. The attending physician stated: "My estimation and management as determined that this patient has a medical necessity beyond the capabilities of emergency department for possible PTA (Peri-tonsillar abscess) and failed outpatient antibiotics. The patient requires further management."

During her hospital stay, a needle aspiration of left peri-tonsillar abscess was performed with purulent discharge noted. A full Incision and drainage of abscess was performed with 5 milliliters of foul-smelling purulent drainage expressed.
Following the procedure, her throat pain improved, and she was able to swallow with less discomfort and was discharged.

The peer-reviewed literature notes that peritonsillar abscesses inpatient have an increased risk of morbidity from the peritonsillar abscess.(1)

The Head and Neck disease MCG (Milliman Care Guidelines) states that: "Clinical Indications for Patient Inpatient Care:

1) Airway blockage or inability to swallowing

2) Abscess or swelling causing significant swallowing difficulty

3) Abscesses or swelling causing airway obstruction or partial obstruction head and neck disease condition, symptom, or finding which emergency and observational care have failed."

The health care plan did not act reasonably nor with sound medical judgment nor the best interest of the patient. The peer-reviewed literature and the MCG guidelines recommend inpatient care for individuals who had difficulty swallowing, possible airway involvement, and failed outpatient antibiotic care.

The inpatient stay was medically necessary for this patient as she had difficulty swallowing, severe pain, possible infringement airway, failure of antibiotic therapy, and was over years of age which is associated with greater morbidity from peritonsillar abscess.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient stay is overturned. Medical Necessity is substantiated.