Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness Of Breath (Pneumonia).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male. He has a past medical history of hypertension, heroin drug abuse, COPD (chronic obstructive pulmonary disease), and HIV (human immunodeficiency virus). He presented to the ED (emergency department) complaining of several days of chills, nonproductive cough, and dyspnea associated with flank pain.

The patient's VS (vital signs) were as follows:  Temperature 99.7, pulse 90, respiration rate 18, blood pressure 131/79, oxygen saturation 96%.  The patient's exam was remarkable for no respiratory distress.  His labs were as follows: WBC (white blood count) 7.6, H/H (hemoglobin/hematocrit) 8.7/26.8, Plt (platelets) 345, Na (sodium) 136, K (potassium) 4.0, CO2 (carbon dioxide) 25, BUN/Cr (blood urea nitrogen/creatinine) 24/1.45, BNP (brain natriuretic peptide) 161. His troponin was less than .01. His urine toxicology was positive for opiates and cannabinoids. His EKG (electrocardiogram) revealed NSR (normal sinus rhythm); T wave inversions in inferior leads. His CXR (chest x-ray) revealed right basilar consolidation.

While in the ED (emergency department), the patient received a Duoneb, dexamethasone, and IV (intravenous) antibiotics.  The patient requested detox from opiates.  His CIWA (clinical institute withdrawal assessment) was 0.  The patient was admitted with CAP (community acquired pneumonia).  Plan of care included IV (intravenous) antibiotics.

No, the Inpatient admission was not medically necessary.

This patient was admitted with CAP (community acquired pneumonia).  The patient was hemodynamically stable and afebrile.  He did not have tachypnea or hypoxia.  The patient had not failed an outpatient level of care.

CURB-65 (confusion, blood urea nitrogen, respiration rate, blood pressure, Age 65+) uses five prognostic variables in providing a risk assessment for patients with CAP (community acquired pneumonia):  Confusion; Urea >7 mmol/L (millimoles per liter) (20 mg/dL [milligrams per deciliter]); Respiratory rate 30 breaths/minute; Blood pressure (BP) (systolic <90 mmHg [millimeters of mercury] or diastolic 60 mmHg [millimeters of mercury]); and Age 65 years.  A CURB-65 (confusion, blood urea nitrogen, respiration rate, blood pressure, Age 65+) score of 0 to 1 indicates low risk and can be treated as outpatients; a score of 2 should be admitted to the hospital; and those with a score of 3 or more should be assessed for care in the intensive care unit.  This patient was at low risk based on him having been assessed with a CURB-65 (confusion, blood urea nitrogen, respiration rate, blood pressure, Age 65+) score  of 1 (BUN [blood urea nitrogen] >20).

Medically necessary services are those which are:  1) Safe, 2) Effective, 3) Generally accepted national standard of medical practice, 4) Not provided primarily for convenience of the patient or the practitioner, and 5) The least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

This patient's severity of illness did not require acute inpatient admission.  The patient could have been safely and effectively treated at lesser level of care.