Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia, Sepsis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a past medical history significant for human immunodeficiency virus (HIV) infection and a recent miscarriage who presented to the hospital with complaints of right-sided back pain and emesis.
Reportedly, the patient presented to a different hospital with profuse vaginal bleeding and passing of products of conception. At that time she was 7- 8 weeks pregnant. It was determined that the patient was having an active miscarriage. She was discharged home with an urgent follow-up with obstetrics/gynecology (OB/GYN). The patient did not attend this appointment. She reported that the vaginal bleeding continued for several days and subsequently resolved.
One day before the day of admission the patient started to experience a fever, fatigue, emesis, and right-sided back pain. She also endorsed a sensation of difficulty breathing.
The patient was in no acute distress. 
A computed tomography (CT) angiogram of the chest was performed. It demonstrated no evidence of a pulmonary embolism, however, the patient had a small right pleural effusion with consolidation in the right posteromedial lung consistent with pneumonia.
The patient was admitted to the hospital with a diagnosis of sepsis that was attributed to community-acquired pneumonia, versus urinary tract infection versus peripheral sepsis. Another admitting diagnosis was HIV. The patient received treatment with ceftriaxone and azithromycin.
In the hospital, the patient was seen by the infectious disease service who recommended the continuation of treatment with azithromycin and ceftriaxone for community-acquired pneumonia. There was low suspicion of a urinary tract infection. As a result of the treatment, the patient's clinical condition started to improve. Blood cultures remained negative, and the Legionella urine antigen came back negative as well. The patient's clinical condition stabilized and she was discharged home.
At issue is the medical necessity of an inpatient stay.

The admission at the acute inpatient level of care was medically necessary.
 
This patient met systemic inflammatory response syndrome (SIRS), Sepsis, and Septic Shock Criteria. This is a risk stratification tool that defines the severity of sepsis and septic shock. Based on the calculations, the patient met sepsis criteria since the patient's temperature was greater than (>) 100.4F, the heart rate exceeded 90 beats per minute, and the white blood cell count (WBC) was > 12,000/cubic millimeter (mm3).
Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. Sepsis represents a spectrum of diseases with mortality risk ranging from moderate to substantial (eg, > 40%) depending on the various pathogens and host factors along with the timeliness of recognition and provision of appropriate treatment.
In general, the treatment of sepsis includes perfusion restoration with intravenous (IV) fluids and sometimes vasopressors, oxygen support, broad-spectrum antibiotics, source control, and other supportive measures. In order to provide treatment for patients with sepsis in the most efficient way in a timely manner, admission at the acute inpatient level of care is the most appropriate. Most likely, the patient presented to the hospital with pneumonia that was complicated by sepsis, especially in the setting of the patient's positive HIV status. Due to pneumonia complicated by sepsis, the care at the acute inpatient level of care was medically necessary.