Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Pneumonia.
Treatment: Inpatient Hospital Stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient is a child with medical history significant for hiatal hernia that presented to the emergency department (ED) with four-day history of worsening cough, abdominal pain, and vomiting, decreased oral intake, and fever to 103 the night prior to presentation. Examination was significant for no acute distress, ill-appearance, dry mucous membranes, decreased breath sounds right middle lung field with rhonchi and rales, no retractions or nasal flaring, and non-focal neurologic exam. Laboratory evaluation was significant for normal white blood cell (WBC) count 7.6 thousand (K) with left shift (60%[percent] neutrophils, 9% bands), elevated C-reactive protein (CRP) 8.9, mildly elevated aspartate aminotransferase (AST) 41 and elevated alkaline phosphatase 193. Chest x-ray revealed bilateral prominent peribronchial lung markings and vague patchy opacities. She was treated with a normal saline bolus and ceftriaxone and admitted to the pediatric floor for further management. Admission orders included continued ceftriaxone, intravenous (IV) fluids, Pepcid, Gaviscon, and Senna once eating. Cultures remained negative. She was deemed stable for discharge to complete a ten-day course of antibiotics with close outpatient follow-up.

This child could have been safely and appropriately managed at a lower level of care. Pneumonia occurs because of inflammation of lung tissue from either infectious or non-infectious causes. Infectious causes include bacteria, viruses, and fungi. Non-infectious causes include aspiration, hypersensitivity reactions, and drug- or radiation-induced pneumonitis. Streptococcal pneumoniae is the most common bacterial pathogen of infants and young children, while Mycoplasma pneumoniae and Chlamydophile pneumoniae are the most common bacterial pathogens of children and adolescents. Other bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Viral pathogens include RSV(Respiratory syncytial virus) and influenza, as well as rhinovirus, human metapneumovirus, parainfluenza, and adenovirus. Bacterial pneumonia typically occurs when organisms from the respiratory tract colonize the trachea and then gain access to the lungs, although hematogenous spread is also possible. Different bacterial pathogens invade according to their own specific pathogenic processes. Viral pneumonia occurs from viral spread along the airways accompanied by direct injury to the tissues with subsequent airway obstruction. Clinically, pneumonia is typically preceded by upper respiratory tract infection symptoms, including cough and runny nose. The type and degree of symptoms of lower respiratory tract infection depend upon the organisms and stage of illness.
This young child presented with worsening cough and high fever, focal decreased breath sounds with rhonchi and rales on exam, and patchy infiltrates on chest x-ray. She was mildly dehydrated with poor appetite, abdominal pain, and vomiting. While it was reasonable to monitor her in the hospital for resolution of vomiting and fever, she was overall hemodynamically stable with no oxygen requirement, no evidence of impending sepsis or respiratory failure, and no significant metabolic abnormalities. She did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care.