Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System/Pneumonia. 
Treatment: Inpatient Hospital. 
The health plan denied the inpatient hospital stay. 
The health plan's determination is overturned. 

The patient is a male with a history of asthma, diverticular disease, and hypertension who presented with complaints of shortness of breath, cough and fever for two days. His fever was high at up to 103 degrees F. He also noted vomiting, diarrhea, and left-sided abdominal pain for the past four days. The abdominal pain felt to the patient like previous episodes of diverticular pain. Emergency Medical Services (EMS) reported the patient was hypoxic at 88% oxygen saturation on room air which did not improve with 4 liters oxygen, and so he was placed on a non-rebreather mask. In the emergency department (ED) his temperature was elevated at 39.5 degrees Celsius. His blood pressure and heart rate were unremarkable; however, he was kept on the 40% non-rebreather mask for persistent hypoxia. He was noted to have crackles on lung examination. Labs were significant for leukocytosis at 16.4 with neutrophil predominance. His rapid flu test was negative. The chest x-ray as read by the ED physician showed evidence of bilateral patchy infiltrates, though the official read was a possible small retrocardiac infiltrate. The patient was started on intravenous (IV) antibiotics and fluids. Blood cultures were sent. He met sepsis criteria due to his leukocytosis, hypoxia and fever in the setting of presumed respiratory infection (pneumonia versus COVID), along with a possible abdominal infection, and was thus admitted to hospital. 

At issue is the medical necessity of the inpatient stay. 

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

Yes, inpatient stay was medically necessary for this patient. By admitting this patient to the hospital, the health care providers acted reasonably with sound medical judgment and in the best interest of the patient. The patient met Milliman Care Guidelines (MCG) criteria for inpatient admission for aspiration pneumonia given that he was hypoxemic with an oxygen saturation of 88% per EMS, which persisted despite them providing 4 liters of oxygen. The persistent hypoxia resulted in the patient being placed on a non-breather mask. After arrival in the ED, his hypoxia persisted, and his physicians were unable to wean him off the non-rebreather mask initially. This indicates persistent hypoxia and warrants admission. The patient was still requiring supplement oxygen to prevent hypoxia and so his continued hospitalization was necessary at that point. At that time, he was in the hospital at least two days and so observation level of care would have been inappropriate. 

Furthermore, this patient met sepsis criteria with his high fever of 39.5 degrees Celsius, leukocytosis, and hypoxia in the setting of infection. Sepsis is a very serious condition that may quickly deteriorate to multi-organ injury and septic shock. Inpatient admission for IV antibiotics and IV fluids were therefore warranted. In addition, his history of nausea, vomiting and abdominal pain, and concern over possible diverticular pain meant keeping this patient nothing by mouth (NPO) and gradually introducing food was prudent. This plan requires inpatient monitoring and serial abdominal examinations. 

An inpatient level of care throughout the patient's entire admission was appropriate for reasons elucidated above.