Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Community Acquired Pneumonia
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay. 
The health plan's determination is overturned.

This case involves a male with a medical history of traumatic brain injury (TBI), Seizure disorder and who is non-verbal who presented to the emergency department (ED) after being sent home from school. He was found to have shortness of breath, cough and showed an elevated respiratory rate of 22/minute as well as tachycardia, with a heart rate of 111 beats per minute (bpm). He had a white blood cell count (WBC) of 19 with bibasilar infiltrates and an effusion noted on his chest x-ray (CXR). He was immediately started on antibiotics and given intravenous (IV) fluids to treat for community acquired pneumonia. He was on supplemental oxygen at 2 liters/minute and had his antibiotics switched to Zosyn and Vancomycin while he was tested for COVID. He had testing which included an elevated C-reactive protein (CRP), a high lactate of 3 and a lactate dehydrogenase (LDH) was elevated at 234. While receiving treatment, his CRP continued to remain elevated and his antibiotics were continued and ultimately changed to Augmentin to cover for aspiration pneumonia.

The question posed is whether the patient required an acute inpatient level of care based on the provided documentation.

The health plan's determination of medical necessity is overturned, in whole.

Based on the provided documentation, I feel that an acute inpatient level of care was warranted for this case. This case involves a male who has a history of traumatic brain injury and is nonverbal. He presented with findings concerning for pneumonia. In the current clinical climate, especially and his area of residence, infection with COVID is a high clinical probability. His initial testing for COVID did come back negative, but he has clinical symptoms and signs that are suggestive of the infection. Based on the clinical picture provided, an inpatient level of care is warranted as the suspected length of stay for a COVID infection would certainly exceed the capabilities of a lower level of care.

A diagnosis of COVID is primarily done via use of rapid testing and use of nucleic acid amplification technology. However, clinical suspicion is warranted when a negative test is returned. Based on the patient's presenting signs and symptoms, a negative COVID test could reflect improper technique in sampling for the virus. Because of this, this patient had a presentation that was certainly suggestive and, due to his nonverbal nature, was not able to provide any other history to help pare down the diagnostic evaluation. The use of CRP has been used in the evaluation of COVID infection and has been demonstrated as a reliable indicator of acute inflammation. While it is not a specific test, in a patient with signs and symptoms concerning for COVID, it does require continued vigilance and monitoring. Standard of care is difficult to come by with this due to the relative newness of the disease. Based on the findings as presented and the clinical information provided, the prudent physician would have expected this admission to extend past the usual observation level of care window and the possibility of rapid clinical deterioration requiring use of invasive mechanical ventilation is reasonably a possibility.