Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient's vital signs included temperature 100.4, heart rate 149, respiratory rate 20 with 98% saturation in room air. Examination revealed no apparent distress, normal pharynx, clear lungs, strong pulses, and non-focal neurologic exam. Rapid influenza and respiratory syncytial virus (RSV) testing were negative. Laboratory evaluation was significant for normal white blood cell (WBC) count, normal metabolic panel, and normal lactate. Chest x-ray revealed central interstitial prominence with peribronchial cuffing and a left lower lobe infiltrate. The patient was treated with anti-pyretics, an intravenous (IV) fluid bolus, and a dose of ceftriaxone prior to admitting for further management of pneumonia. Admission orders included pulse oximetry, regular diet for age, ceftriaxone, azithromycin, albuterol, IV fluids, and anti-pyretics. The patient's fevers resolved and her appetite improved, but she continued to have a harsh productive cough. The grandmother raised concerns about the mother and her ability to medicate the child. The patient was ultimately deemed stable for discharge. 

Pneumonia occurs as a result 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 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. Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis, and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema or abscess.

This young female child presented to the ED with subjective fevers and cough. She was not wheezing, not in any respiratory distress, had no supplemental oxygen requirement, had no chronic underlying medical condition, was taking fluids by mouth, and was overall stable. While it was not unreasonable to bring her to medical attention for evaluation, she had not failed outpatient therapy and could have been safely managed in the outpatient setting. While the grandmother raised concerns about the child's ability to take medications at home, this could have been addressed with outpatient services and the primary care practitioner's office. Overall, the acute inpatient admission was not medically necessary.