Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Influenza
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient was 9 weeks pregnant when she presented to the emergency department (ED) with four days of a fever, chills, cough, congestion and body aches. She reported that she was diagnosed with influenza and was prescribed Tamiflu as an outpatient two days prior to admission, but her symptoms continued to worsen. Initial evaluation in the ED was notable for a fever to 100.9 degrees Fahrenheit (F), tachycardia (heart rate of 143), tachypnea (respiratory rate 22), acutely ill appearance, dry mucus membranes and a positive influenza B antigen test. Her next set of vital signs showed a drop in blood pressure to 92/54 with continued tachycardia to 112 despite receiving IV fluids. She was started on empiric antibiotics and admitted for additional workup of sepsis.
Infectious disease was consulted and recommended continuing empiric broad-spectrum antibiotics, including IV vancomycin, piperacillin/tazobactam and azithromycin. She was continued on Tamiflu with additional infectious workup pursued, including blood and urine cultures, a respiratory viral panel and testing for specific pathogens like Legionella and Mycoplasma. Obstetrics was also consulted but did not recommend any additional interventions. Overall clinical improvement was documented, but she continued to have tachycardia and a low blood pressures. Procalcitonin was found to be less than 0.05, and blood cultures showed no growth, so intravenous (IV) antibiotics were stopped with Tamiflu and oral azithromycin continued. She continued to improve overall with no growth from blood cultures, so she was discharged with Tamiflu and azithromycin to complete a 5-day course of each. At issue is the medical necessity of an inpatient stay.
The inpatient stay was medically necessary. The patient had initial signs of hemodynamic instability, including hypotension and tachycardia that persisted despite IV hydration. Particularly in her immunocompromised state, she was at a high risk for progression to septic shock with an attendant risk of mortality. Inpatient hospitalization was necessary to exclude the presence of a secondary bacterial infection like pneumonia or bacteremia. Although overall clinical improvement was documented , her continued stay was appropriate to allow blood cultures adequate time to incubate and to ensure sustained hemodynamic stability in light of the continued tachycardia and low blood pressure. She had evidence of hemodynamic instability and severe sepsis despite fluid initial fluid resuscitation and broad-spectrum IV antibiotics.  These issues warrant inpatient admission, as they are unlikely to resolve during a brief (overnight) hospital stay, and they place the patient at high risk of requiring intensive care unit (ICU) transfer for interventions like vasopressors, should her hypotension fail to improve. A lower level of care would have placed her at an unacceptably high risk of worsening sepsis, hypoxic respiratory failure, renal failure, fetal demise and death. She required hemodynamic monitoring, rapid administration of IV antibiotics and fluid boluses, as well as expedited workup for a source of sepsis.