Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient Hosptial Stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female with history of anxiety, bipolar disorder, methadone dependence, osteoarthritis, obstructive sleep apnea, and central canal stenosis who presented with right lower rib and back pain after being kicked on her right side. Her initial vital signs revealed a temperature of 97.5, heart rate (HR) 88, blood pressure (BP) 133/69, respiratory rate (RR) 18, peripheral capillary oxygen saturation (SpO2) 99 percent (%) on room air. The initial examination documented right lower rib and thoracic tenderness. The initial laboratory testing revealed a white blood cell count (WBC) of 7.7, hemoglobin 10.4, platelets (Plt) 173, blood urea nitrogen (BUN) 25, creatinine 1.26, sodium 140, carbon dioxide (CO2) 27, Troponin T 0.016 and her creatine phosphokinase (CPK) was 104.
The computed tomography (CT) of the chest revealed small patchy infiltrates in the right middle lobe and consolidation in the right lower lobe with additional satellite infiltrates. The patient was placed in the hospital thereafter. The admitting physician documented accidental findings of lobar pneumonia, she was asymptomatic, afebrile, and had no elevated inflammatory markers. The treatment plan included analgesia, intravenous fluids and empiric Levofloxacin. The patient was deemed medically stable and discharged to home.

Evaluation and management could have been performed at an alternate level of care. The Confusion, Urea, Respiratory Rate, Blood Pressure and Age greater than or equal to 65 years of age (CURB-65) score was 1, the Confusion, Respiratory Rate and Blood Pressure (CRB-65) score was 0, and the Pneumonia Severity Index (PSI) was a class of two (II).
Ranzani, et al. note Community-acquired pneumonia (CAP) represents a significant infection burden worldwide, and it is often complicated by sepsis. Early recognition of sepsis is fundamental to guide treatment, improve outcomes, and decrease costs. In contrast, in patients with uncomplicated infection, over-treatment should be avoided to prevent unnecessary harm. In patients with CAP, several scores have been developed to identify high-risk patients and support therapeutic decisions. Two of these scores, CURB-65 and Pneumonia Severity Index (PSI), are well-validated scores to support CAP management and prognosis. Simplifications of CURB-65 and the CRB-65 have been developed and validated to facilitate the risk stratification process; these simplified scores do not require blood tests.[1]

Musher, et al. note that community acquired pneumonia has long been recognized as a major cause of death and has been studied extensively since the late 1800's. Scoring of severity is an important step in the initial evaluation and management of a patient suspected of having pneumonia. Validated instruments include the PSI, the CURB-65 score, and the guidelines of the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS). The decision to hospitalize a patient ultimately depends on the physician's judgment, but all factors that are contained in these scoring systems should be considered. Because the PSI is so age-dependent, an elevated score in a young adult should be regarded with alarm.[2] 

In this particular situation, the patient was low-risk and had a score that indicated safe management as an outpatient. The patient presented with right rib and back pain after being kicked in the area. The patient was afebrile, hemodynamically stable, without hypoxia, and without elevated inflammatory markers. Treatment included empiric antibiotics and supportive care. Following one day, the patient was deemed medically stable and discharged to home. No other issues or complications were documented.