Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history significant for asthma, chronic obstructive pulmonary disease (COPD), acquired immunodeficiency syndrome (AIDS), polysubstance abuse, hypertension, and hepatitis B infection who presented to the hospital with complaints of worsening shortness of breath over the course of two to three days. This was associated with intermittent non-radiating mid sternal pleuritic chest pain, which the patient described as sharp.
At the same time, the patient denied a cough or increased sputum production. The patient endorsed generalized malaise and fatigue. Reportedly, she was overall noncompliant with her medications.
The patient also mentioned intermittent episodes of rectal bleeding that she attributed to her history of colon cancer. However, the last time she had bleeding was one month before the presentation.
At the time of the initial evaluation, the patient was afebrile. Her blood pressure was 139/72, pulse rate was 80 beats per minute, respiratory rate was 18 breaths/minute and oxygen saturation was 100% on room air. The patient looked obese, ill-appearing, but not toxic or diaphoretic. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits except for the left eye cataract. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lung exam demonstrated diminished breath sounds bilaterally at the bases. There was a trace of bilateral lower extremity edema. The rest of the exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 4.0, hemoglobin 10.9, hematocrit 33.1, and platelets 157. The sodium was 141, potassium 3.9, chloride 104, bicarbonate 26, blood urea nitrogen (BUN) 17, and creatinine 0.42.
Computed tomography (CT) angiogram of the neck revealed atherosclerotic changes in the carotid bifurcations, especially on the left with moderate stenosis. CT angiogram of the head revealed anterior circulation stenoses. A CT scan of the head showed no acute hemorrhage. There was an extensive sequela of old small vessel ischemia. A CT scan of the chest, abdomen, pelvis with contrast showed possible colitis in the rectal sigmoid colon. There was possible enteritis involving the small bowel.
The patient was admitted to the hospital with a COPD/asthma exacerbation secondary to community-acquired pneumonia and possible opportunistic infections secondary to AIDS.
The patient was started on intravenous Ceftriaxone and Azithromycin. The patient received treatment with bronchodilators and SoluMedrol.
In the hospital, the patient was seen by a neurologist due to abnormal results of the CT scan of the head and neck. Magnetic resonance imaging (MRI) of the brain was recommended. It demonstrated no acute parenchymal hemorrhage or infarct in the brain.
During the hospital stay, the patient's clinical condition somewhat improved. She decided to sign out against medical advice.
At issue is the medical necessity of an inpatient stay.

The acute inpatient level of care was medically necessary, considering the high probability that the patient had pneumonia, being immunocompromised due to AIDS, as well as the previously reported history of medical noncompliance.
Based on the clinical evaluation, it was determined that there was a high probability of the patient having pneumonia that was associated with a COPD/asthma exacerbation.
Considering the patient's immunocompromised status due to AIDS, the admission at the acute inpatient level of care was reasonable to provide treatment with intravenous antibiotics, bronchodilators, and monitor the respiratory status and the response to treatment with antibiotics.
In addition, it was noted in the chart that the patient had a history of medical non-compliance, which increased the chances for adverse outcomes if the pneumonia was not adequately treated.