Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Respiratory System.
Treatment:  Inpatient hospital.

The insurer denied the Inpatient stay.  The denial is upheld in whole.

The patient is a male with a past medical history significant for asthma, chronic obstructive pulmonary disease (COPD), and ongoing tobacco use, who presented to the emergency department with complaints of fever, dry cough, and chest congestion.  Reportedly, three days before his presentation the patient felt nauseous and had several episodes of non-bloody emesis.  Since then, the patient reported decreased oral intake, although there were no further episodes of emesis.  He stated that one of his employees had similar symptoms a few days prior.

When first seen in the emergency department, the patient had a temperature of 100.2 Fahrenheit (F), heart rate 103 beats per minute (bpm), blood pressure 125/70, with respiratory rate 20, and oxygen saturation of 96% on room air.

The patient appeared to be a well-developed, well-groomed, well-nourished individual.  He had a normal head, eyes, ears, nose, throat (HEENT) exam.  The patient had diminished breath sounds bilaterally.  He had a regular rate and rhythm, without murmurs, rubs, or gallops.  The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that white blood cell count was 13.44, hemoglobin was 13.1, hematocrit was 38.3, and platelets were 236.  Sodium was 135, potassium was 3.9, chloride was 101, bicarbonate was 27, blood urea nitrogen (BUN) was 18, creatinine was 0.8, and glucose 120.

Chest x-ray demonstrated a new ill-defined nodular opacity in the right lower lobe, which could represent atypical pneumonia or infectious bronchiolitis.

The patient was admitted to the hospital with a diagnosis of pneumonia based on the presence of fever, chills, elevated white blood cells with bandemia, abnormal results of the chest x-ray.  In the hospital, the patient received treatment with intravenous Levaquin, Solumedrol, intravenous fluids. Another clinical problem was COPD.  It was indicated that the patient had diminished breath sounds bilaterally.  As it was mentioned above, the patient received treatment with Solumedrol and bronchodilators.  During the hospital stay the patient's clinical condition steadily improved and the patient was discharged home.

The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld in whole.

In this particular clinical situation, the patient had a history of asthma and COPD.  In order to assist with the determination on the treatment level, the CURB-65 Score for Pneumonia Severity was used.  This is a risk-stratification tool that estimates the mortality of community-acquired pneumonia to help determine treatment level.  Based on the calculations, the patient received 0 points.  This means that the patient belonged to a low-risk group of 30-day mortality and could have been treated at a lower level of care status. 

Based on the review of the medical records, this patient had a mild COPD exacerbation.  It was mentioned that the patient had diminished breath sounds bilaterally, which was very common in patients with COPD even without acute exacerbation.  It was also indicated that the patient required endotracheal intubation 15 years before his current presentation.  Along with continuous tobacco use, those circumstances increased the risk of adverse outcomes.  However, overall, the patient remained in stable clinical condition, had no signs of respiratory failure, and did not even require supplemental oxygen.  His response to treatment was adequate, the patient was able to tolerate oral intake including antibiotics.  The review of the medical records demonstrated that he did not require any diagnostic studies or procedures necessitating an inpatient stay.  This patient could have been admitted for monitoring to ensure the stability of respiratory status as well as an adequate response to treatment with antibiotics, bronchodilators, and corticosteroids; however, this did not require an acute inpatient stay and could have been managed at a lower level of care status.