Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia. 
Treatment: Inpatient stay. 
The insurer denied coverage for inpatient stay. 
The denial is upheld. 

The is a patient who presented with nausea with emesis. The patient reported abdominal pain, rated as 8 out of 10. The patient had a week of upper respiratory symptoms. Chills and emesis were also noted. The patient was diagnosed with pneumonia and the patient received intravenous (IV) antibiotics, IV fluids and supportive care. 

The patient was to be discharged; however, the patient did not want to go home due to feeling weak. Review of systems did not show patient had shortness of breath. Lung sounds were noted to be clear to auscultation bilaterally in all fields, no wheezing, rales, or rhonchi noted. Cardiovascular assessment was noted with regular rhythm and rate (RRR), with palpable pulses at radial and dorsalis pedis bilaterally, and capillary refill less than two seconds. The chest x-ray did show pneumonia; however, the patient's vital signs were stable (temperature was 98.1 degrees Fahrenheit, pulse 73, respirations 22, blood pressure 205/97 [the patient has a history of hypertension, and substance abuse that includes heroin], and pulse oximetry was 94 on room air). The patient did not require oxygen. The initial white blood cell (WBC) count was 8.7 with hemoglobin and hematocrit of 15.3 and 45.4 for the complete blood count. For the basic metabolic panel, sodium was 137, chloride was 102, glucose was 116, blood urea nitrogen (BUN) was 6.6 with creatinine of 0.7, and potassium of 3.7 with bicarbonate (HCO3) of 27. The patient was given antibiotics in the emergency department and could have been discharged home on oral antibiotics. The patient was positive for opiates and marijuana in their urine, and urinalysis was negative for infection. In addition, the respiratory swab was negative. 

The patient did not have evidence of hypoxia, changes in mentation, or two lobes involved. Additionally, despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet the patient did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such the care could have been rendered at a lower level. 
"Pneumonia is a common respiratory infection, and its diagnosis is among the mainstays of emergency medicine. Although classic symptoms include cough, chest pain, and fevers, it is important to remember that at extremes of age, the presenting features may vary. In these groups, symptoms are more likely to include headache, nausea, and abdominal pain. The diagnosis of pneumonia can be made based on symptoms, imaging, and clinical examination findings, and treatment should be targeted toward the most likely organisms in the particular patient. Pneumonia is a common cause of sepsis and early and aggressive treatment should be considered to minimize the risk of deterioration" (2). 

"Acute abdominal pain (AAP) is a common symptom and reason for encounter in family practices and emergency rooms. About every tenth hospital emergency room consultation is dealing with AAP, the most important reason is the suspected acute abdomen. Important diagnostic considerations and clarification steps in family practice and emergency room are presented with the question: in which cases further treatment must be inpatient - or can be done on an outpatient basis" (1).                                                      
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient stay is not substantiated.