Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/Pneumonia. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is upheld. 

The patient is a female child with no significant medical history who presented to the emergency department (ED) with a two-week history of tactile fever and worsening cough. She was seen in another ED a week prior, where a viral swab was negative, and she was discharged home with symptomatic treatment. The cough worsened, keeping her awake at night. She had congestion, rhinorrhea, decreased appetite, and decreased urine output. Vital signs included a temperature of 37C., a heart rate of 124 beats per minute (bpm), a respiratory rate 20/minute with 95% oxygen saturation. Examination was significant for tired appearance, no visible nasal discharge, clear lungs with transmitted breath sounds, benign abdomen, and a non-focal neurologic exam. Labs and chest x-ray were obtained. Labs were significant for a carbon dioxide (CO2) of 20, a C-reactive protein (CRP) of 6.29, and a white blood cell count (WBC) count of 13.8. Rapid influenza A and B were both negative. The chest x-ray was significant for a subtle left perihilar interstitial infiltrate and linear bands of opacity involving the right lower lobe. She was only able to tolerate a few small sips of water, insufficient to sustain herself. She was given one dose of Amoxicillin and a normal saline bolus prior to admission for a diagnosis of oral intolerance and pneumonia. Admission orders included regular diet for age, droplet precautions, maintenance intravenous (IV) fluids, nebulized normal saline every four hours, Azithromycin, follow-up cultures and Covid polymerase chain reaction (PCR). 
She did well overnight with no fevers, improvement in congestion, closer to baseline. Blood cultures were negative. Her exam was significant for transmitted breath sounds in the upper lung fields. IV fluids were decreased with plans to discontinue as her oral intake was improving. She did well over the course of the day, deemed stable for discharge in the afternoon. 

At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination of medical necessity upheld, in whole. 

No, an acute inpatient admission was not medically necessary. 

Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema, abscess, or sepsis. 

This young female child presented with cough, fever, and decreased appetite. A chest x-ray was suggestive of atypical pneumonia. She was not able to pass an oral challenge in the ED. While it was reasonable and medically necessary to monitor her for adequate oral intake and treat her lower respiratory tract infection, she was hemodynamically stable. She had no oxygen requirement, no severe respiratory distress, and no evidence of impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at a lower level of care.