Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient Hospital

Diagnosis: Pneumonia
Treatment: Inpatient Admission

The health plan denied: Inpatient Admission
The determination is: Overturned

The patient was an infant with Trisomy 21, hypothyroidism, and an atrial septal defect, who presented with a cough and increased work of breathing.
He started coughing while taking in liquids, and was having spit-ups after feeds with some choking. He subsequently developed increased work of breathing with retractions and tachypnea. He was also irritable, was sleeping less than usual, and was taking a little less food. He also was reported to have episodes of decreased alertness that lasted seconds with return to regular activity. A neurology appointment was scheduled for March. He was seen for an endocrinology appointment and was found to have a cough and increased work of breathing. He was therefore sent to the emergency department for further management.
In the emergency department, his lung exam revealed retractions with rhonchi and rales. Laboratory values were obtained as well as a chest x-ray, which revealed bilateral opacities consistent with aspiration pneumonia. The gastroenterology team was consulted who recommended placement of a nasogastric tube (NGT) and admission for evaluation by speech and language pathology.
He was admitted to the hospital and continued to have subcostal retractions and tachypnea. He was treated with continuous feeds through the nasogastric tube and clindamycin. He was evaluated by the speech and language pathologists who recommended continuing with NGT feeds for primary nutrition. His feeds were condensed, and he tolerated them well. He remained stable, and his respiratory status improved. By the next day, he was felt to be stable for discharge to home for continued treatment and follow up as an outpatient.
The health plan's determination of medical necessity is overturned in whole.
Yes, the requested health service/treatment of inpatient hospital admission was medically necessary for this patient.
This is a young infant with a complex medical history, including Trisomy 21 and congenital heart disease, who presented with a cough and increased work of breathing and x-ray findings consistent with aspiration pneumonia. He required prompt initiation of treatment with antibiotics along with monitoring of his breathing status, and he needed to be kept from eating or drinking until a safe feeding plan was established.
The decision making at the time of admission for this patient was consistent with his young age, the presence of complex medical condition with evidence of aspiration pneumonia and increased work of breathing, and the need for prompt initiation of treatment, development of a new feeding plan, and close monitoring for potential deterioration of clinical status.
 Hospitalization for pneumonia generally is warranted for infants with respiratory distress with retractions and difficulty breathing, and for those with an underlying condition that may predispose to a more serious course of pneumonia (including cardiopulmonary disease and genetic syndromes). This infant has Trisomy 21 as well as congenital heart disease, and also had suspicion for aspiration with feeds, which required prompt evaluation as well as development of a treatment plan and a safe feeding plan. Therefore, the inpatient admission was medically necessary.