Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

Treatment: Inpatient Admission

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

This is an infant child who presented to the Emergency Department (ED) with a cough, congestion, multiple episodes of vomiting and fever for two days.  A physical examination was performed revealing clear lungs bilaterally and Otitis media of the right ear.  A chest x-ray was performed revealing bilateral perihilar infiltrates.  Influenza test was done with negative results.  Blood work was obtained revealing a white blood cell (WBC) count of 7.0, neutrophils 24.0, lymphocytes 64.0, a chloride of 108, and a creatinine of 0.47.  Blood cultures were drawn with negative results.  He received intravenous (IV) fluids and IV antibiotics.  Nebulizer respiratory treatments and oral steroids were given.  The patient was medically stabilized and then discharged home.

According to UpToDate: Pneumonia in children: Epidemiology, pathogenesis, and etiology:

"Community-acquired pneumonia

Overview - The true prevalence of the various etiologic agents in community-acquired pneumonia (CAP) in children is uncertain.  Studies investigating the etiology of childhood pneumonia have been performed in populations of various ages, in various settings, and using a variety of microbiologic techniques.  Because direct culture of infected lung tissue requires invasive techniques, published studies primarily use laboratory tests that provide indirect evidence of etiology.  These indirect methods include nasopharyngeal culture, blood culture, polymerase chain reaction, and serology.  

Despite these problems, systematic reviews have identified some consistent trends and conclusions regarding the etiology of CAP in children, which are listed below:

1) S. pneumoniae is the most common bacterial cause of pneumonia in children 2) Viruses alone account for 14 to 35 percent of cases, and up to 50 percent of cases in young children 3) Viruses are more commonly identified in children younger than five years 4) In children older than five years, Mycoplasma pneumoniae, and Chlamydia pneumoniae are more common

Respiratory syncytial virus (RSV), a member of the Paramyxoviridae virus family, is
the most common viral pathogen responsible for pneumonia in children younger than
five years.  RSV pneumonia frequently represents an extension of bronchiolitis.  Other
viral causes of pneumonia in children younger than five years include some of the
following:

1) Influenza A and B viruses 2) Parainfluenza viruses, usually type 3 3) Adenovirus serotypes (1, 2, 3, 4, 5, 7, 14, 21, and 35) have been reported to cause pneumonia; serotypes 3, 7, and 21 have been associated with severe and complicated pneumonia 4) Human metapneumovirus, identified in 2001, is a common cause of lower respiratory tract infections in children; most children have been infected by five years of age"

According to UpToDate: Pneumonia in children: Inpatient treatment:

"HOSPITALIZATION

Hospitalization is also warranted for a child of any age whose family cannot provide appropriate care and assure compliance with the management of plan.  Additional indications for hospitalization include some of the following:

1) Hypoxemia (oxygen saturation [SpO2] <90 percent in room air at sea level) 2) Dehydration, or inability to maintain hydration orally; inability to feed in an infant 3) Moderate to severe respiratory distress: Respiratory rate >70 breaths/minute for infants <12 months of age and >50 breaths per minute for older children; retractions; nasal flaring; difficulty breathing; apnea; grunting 4) Toxic appearance (more common in bacterial pneumonia and may suggest a more severe course)"

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.