Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The Inpatient admission was medically necessary.

The patient is a teenage female with medical history significant for depression and anxiety. She was referred to the ED for evaluation of cough, chest pain, and persistent fever to 100.8. She had been seen twice in the previous week to ten days, once by her primary care practitioner and once at another ED, and she was diagnosed with community acquired pneumonia (CAP) with left lower lobe infiltrate. Viral panel had been positive for adenovirus. She was initially treated with two days of Augmentin, changed to cefdinir for seven days, and then two days of azithromycin with no substantial improvement. Albuterol also provided no benefit. 

The patient's vital signs in the ED included temperature 99.9 (to 100.8), heart rate 97, respiratory rate 16 with 96% saturation, and blood pressure 121/64. Examination was significant for dry appearance, mild audible murmur, mild wheezing on the left with no increased work of breathing, and non-focal neurologic exam. Laboratory evaluation revealed normal WBC (white blood cell) count, unremarkable metabolic panel, urinalysis with trace protein and large hemoglobin and trace leukocyte esterase and 15 ketones, elevated CRP (C-reactive protein) (1.526), elevated ESR (erythrocyte sedimentation rate) (55), and negative rapid influenza and RSV (respiratory syncytial virus). Electrocardiogram was significant for sinus tachycardia. Chest x-ray revealed (persistent) posterior left lower lobe consolidation. 

The patient was treated with Toradol, a normal saline bolus, acetaminophen, and ceftriaxone. She was admitted for treatment of pneumonia due to failed outpatient management. Admission orders included ceftriaxone, consideration for respiratory vital panel, follow-up cultures, and ibuprofen for the chest pain. Her chest pain improved with ibuprofen and her cough improved with guaifenesin. Since she had already been treated with ten days of antibiotics, the ceftriaxone and azithromycin were not continued. She was ultimately deemed stable for discharge with diagnosis of viral pneumonia with instructions to continue ibuprofen and guaifenesin as needed.

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 or abscess.

This teenage female was referred to the ED with persistent cough, fever, and chest pain despite appropriate outpatient antibiotic treatment for community acquired pneumonia confirmed with chest x-ray. Repeat chest x-ray in the ED showed persistent infiltrate so she was admitted for further treatment. Despite the ultimate diagnosis of viral pneumonia and the relatively short duration of her hospital stay, the care that she received after failing outpatient therapy and multiple visits to the primary care practitioner and ED was most consistent with acute inpatient management. She could not have been appropriately managed at a lower level of care (it had already failed).