Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Health care-associated pneumonia (HCAP).
Treatment:  Inpatient admission level of care.

The insurer denied coverage for the inpatient admission level of care.  The denial is overturned. 

This is a female patient, who was a recent postoperative status.  She presented to the Emergency Department (ED) the day after her recent hospital discharge with complaints of fevers to 102.5 at home.  The patient also reported cough, shortness of breath, fatigue, abdominal discomfort, and transient loss of smell.  The patient reported that her maximum temperature was 103, for which she had taken Tylenol at home.  In the ED, the patient's vital signs were: temperature 98.1, blood pressure 122/72, respiratory rate 18, heart rate 74, and oxygen saturation 93% on room air.  On examination, the patient had rhonchi on bilateral lungs.  The patient's abdomen laparoscopic wounds were clean, and the patient was awake and alert.  The patient's chest X-ray revealed right paratracheal opacity with atelectasis.  The patient's computed tomography angiography (CTA) was negative for pulmonary embolism but revealed right upper lobe (RUL) and right lower lobe (RLL) consolidative changes consistent with pneumonia/atelectasis.  The patient's procalcitonin level was elevated at 0.44.  Given this patient's presentation with fever, leukocytosis with left-shift, and multi-lobar opacities on imaging in the setting of elevated procalcitonin, the patient was diagnosed with health care-associated pneumonia (HCAP).  Pulmonary service evaluated the patient and also felt that the patient had HCAP and recommended patient's admission to the hospital and starting on broad spectrum antibiotics.

Based on the review of the medical record and literature review, an inpatient level of care was medically necessary for this patient.  The patient was a recent postoperative status, who presented with clinical findings suspicious for HCAP, multi-lobar pneumonia that required broad spectrum intravenous (IV) antibiotic administration and close monitoring.  The patient had abnormal labs, including elevated procalcitonin and leukocytosis with left-side shift.  The patient spiked a fever up to 101.8 overnight, which was also of concern.  Though he patient's culture resulted negative for methicillin-resistant Staphylococcus aureus (MRSA) on day 3 of admission, this was not certain at the time of initial presentation and admission.  Based on the review of the medical record, when the patient's MRSA resulted negative, the patient was switched to oral antibiotic therapy, and once the patient's laboratory results normalized and the patient remained afebrile, the patient was discharged appropriately.

HCAP is a serious condition and carries significant risk for morbidity and mortality.  Given this patient's recent postoperative status and underlying severe obesity and multi-lobar infiltrates on chest imaging, it was medically appropriate to admit the patient to the hospital.  The patient continued to have fevers even after hospitalization and needed close observation, as she was being treated with IV antibiotics to avoid further complications.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient admission level of care is substantiated.  The insurer's denial should be overturned.