Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia 

Treatment: Hospital Admission

The insurer denied coverage for hospital admission

The denial is upheld

The patient presented to the Emergency Department (ED) late at night with complaints of fever and shortness of breath for 1 week which was worse over the previous 2 days.  
Vital signs (V/S) at presentation to the ED were temperature (T) 103F, heart rate (HR) 94, respiratory rate (RR) 18, blood pressure (BP) 132/80 mm Hg and oxygen (O2) saturations 95 %. The patient appeared to be non-toxic as per medical doctor note.  Lungs showed no increased work of breathing.  The patient was ambulatory and alert and oriented x3 (person, place and time). Chest x-ray was read as bilateral pneumonia.  White blood cell (WBC) count was 21.9K.  Electrolytes were within normal limits/blood urea nitrogen/Creatinine were 11/0.7.  Covid Test was negative.  Inflammatory markers were elevated.  D-Dimer, C-reactive protein and Ferritin were high.  The patient was admitted with a diagnosis of community acquired pneumonia.  The patient was started on treatment with intravenous (IV) Rocephin and Azithromycin.  The patient was also given IV Fluids.

As per History & Physical V/S were T 99.5, RR 18, BP 130/77, HR 92 and O2 saturations were 96%.  The exam revealed decreased breath sounds over the right (R) base.  There was some infrascapular pain also reported R > left (L).  Lactate levels were normal.  Troponin was negative.  Procalcitonin was 0.33.  The patient underwent electrocardiogram (EKG) which revealed some left ventricular hypertrophy.  Computed tomography angiography (CTA) was done.  There was no pulmonary embolism (PE).  Right lower lobe (RLL) showed consolidation.  A deep vein thrombosis (DVT) study was done due to elevated D-Dimer and it was negative for DVT.

The patient remained stable after admission.  As per attending note the patient was in no acute distress and was alert and oriented x3.  He complained of some R pleuritic type chest pain.  T 98.8 F, HR 86, BP 123/73 and O2 saturations 98%. The patient was continued on antibiotics.  Repeat WBC was 9.6K.  This patient did not need acute inpatient hospitalization.  He could have been placed in observation status (which could be for up to 48 hours) while diagnostic testing and treatment were initiated.

This patient had a CURB 65 (confusion, urea, respiratory rate, blood pressure & 65 years or older) score of Zero.  The patient was described to be in no acute distress and non-toxic looking.  He could have been safely placed on Observation while testing and treatment were initiated.  The patient did not have significant comorbidities (other than hypertension), the patient was hemodynamically stable, not hypoxic and was able to tolerate oral intake.  No failure of response to outpatient management was documented.

This patient could have received a few doses of IV antibiotics and subsequently switched to oral antibiotics and discharged home on them with close follow-up in an outpatient setting.  The patient's pneumonia was in the RLL.  There was no evidence of PE or myocardial infarction (MI).  He responded to the antibiotics and his WBC responded appropriately with initiation of antibiotics and was at normal levels. The patient could have been discharged home on oral antibiotics after a period under observation after switching to oral antibiotics and then followed up closely in the outpatient setting.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.