Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

This is the case of a female with past medical history of obesity who presented to the emergency department from urgent care with shortness of breath and cough. On presentation, she was afebrile with blood pressure 142/97, heart rate 111, respiratory rate 33, and with oxygen saturation 90% on room air and 95% on 2 liters (L). Exam noted right-sided crackles. Labs resulted with white blood cell (WBC) 16.2, hemoglobin (HGB) 9.8, and platelets 218. Sodium was 133, potassium 3.51 blood urea nitrogen (BUN) 7, creatinine 0.63, total bilirubin 6.7, aspartate aminotransferase (AST) 146, alanine aminotransferase (ALT) 70, and Alk Phos was 246. International normalized ratio (INR) was 1.5, troponin was 0.05, and hepatitis panel was non-reactive. Chest x-ray showed right lower lobe infiltrate. The patient was admitted with concerns for pneumonia and elevated liver enzymes and plans for intravenous (IV) antibiotics, nebulizers, oxygen support, abdominal ultrasound, and gastroenterology consultation.

Gastroenterology saw the patient with assessment that her liver enzymes were trending down and she likely had alcoholic liver disease with plans to pursue magnetic resonance imaging (MRI) to further evaluate, check lipase, follow liver function tests, and give vitamin K 10 milligrams (mg) IV x 1 and then repeat prothrombin time (PT)/INR. Plan otherwise for her community-acquired pneumonia was to discontinue ceftriaxone and continue doxycycline in addition to watching for potential alcohol withdrawal.

The patient remained hemodynamically stable without fever, hypotension, tachycardia, tachypnea or documented hypoxia. Exam noted lungs that were clear to auscultation and mild left upper quadrant tenderness. Repeat WBC was 3.7 with total bilirubin 4.4, AST 111, ALT 61, Alkaline phosphatase 203, and INR 1.2. MRI of the abdomen showed diffuse fatty infiltration of the liver without common duct or pancreatic duct dilatation. Plan was to discontinue ceftriaxone and continue doxycycline alone for antibiotic coverage and to continue to monitor her liver function. The patient was ultimately discharged.

The health plan's determination is upheld in whole.

This is a patient who presented with community acquired pneumonia and elevated liver enzymes. She was tachypneic on presentation to 33 with an oxygen saturation of 90% on room air with tachypnea resolved quickly after nebulizers and initiation of IV antibiotics. It is notable that even with her initial respiratory rate of 33, her Pneumonia Severity Index (PSI)/PORT score was risk class III with 0.9-2.8% with treatment at a lower level of care setting reasonable, particularly given her rapid improvement. She otherwise had elevated liver function tests that improved after admission with any sort of obstruction or other abnormality requiring acute intervention ruled out within a reasonable period of monitoring and with gastroenterology noting that she had alcoholic liver disease with primary recommendation to stop drinking alcohol. An inpatient stay was not medically necessary in the setting of pneumonia without hypoxia, persistent tachypnea, or other high risk features (no history of immunocompromise, other acute cardiopulmonary process, history of congestive heart failure, or kidney disease with PSI/PORT score III) and with liver enzymes that were mildly elevated in the setting of alcoholic liver disease and improved quickly. The patient's care could have been provided at a lower level of care setting.