Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Viral Pneumonia. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is the case of a is a man with a past medical history including heart failure, coronary artery disease (CAD), aortic aneurysm, hypertension, diabetes mellitus, hyperlipidemia, and cerebrovascular accident. The patient presented to the Emergency Department (ED) with complaints of chest pain with minimal exertion, respirophasic, decreased exercise tolerance from 1.5 miles to even minimal standing, as well as increased fatigue. Tachycardia noted during initial triage. He then reported a sharp left lower chest pain, radiating to the left scapula, worse when lying down. There was associated shortness of breath while waiting for the ambulance, and a report of subjective fever although temperature in the ED was 99.6 degrees, later rising to 100.6. There was review of a cardiac catheterization that had been performed months earlier showing multivessel CAD, and subsequent cardiology notes, with coronary artery bypass grafting (CABG) evaluation pending. Exam was unremarkable other than tachycardia with heart rate of 120 beats per minute. Labs and electrocardiogram (EKG) were unremarkable. Initial impression was rule out acute coronary syndrome (ACS) versus dissection versus renal colic versus pneumonia versus other. The plan included transthoracic echocardiogram (for history of cardiomyopathy), cardiology consultation (with the notation that prior episodes of chest pain had been atypical, despite known severe CAD), and discontinue antibiotics as no evidence of pneumonia although follow temperature and blood cultures. While awaiting a bed, there was recurrence of chest pain, 7/10. 

During his hospitalization, fever had risen to 100.6. Abdominal ultrasound had been reassuring. Computed tomography (CT) had been reassuring, other than left lower lobe nodularity and ground-glass opacities. This was believed to be the cause of his chest discomfort, in retrospect, due to associated inflammation. The musculoskeletal pain was eventually controlled with lidocaine patch and Tylenol. 

While he was ultimately diagnosed with likely viral pneumonia, his presentation included fever, tachycardia, and an abnormal CT with fairly non-specific findings that suggested bacterial pneumonia. Further observation was warranted on this basis, as well, particularly in a patient with significant comorbidities including coronary artery disease and diabetes mellitus. His CURB-65 (confusion, urea nitrogen, respiratory rate, blood pressure, 65 years or older) score of 1 (for age, augmented by significant comorbidities as above) is associated with a mortality rate of 2.1% (percent), and inpatient management, typically in a general medical unit, is recommended; more concerning assessment is correlated with the PSI (pneumonia severity index) risk score of 95, associated with a mortality of 9.3%. PSI is the preferred risk score in this context. 

The health care plan did not act reasonably and with sound medical judgment, nor in the best interest of the patient. 

Inpatient admission is considered medically necessary. His cardiac risk was significant He had recently been identified as having severe coronary artery disease and was awaiting CABG (coronary artery bypass graft), there was concern for pneumonia, and he was febrile and tachycardic. His workup was ultimately reassuring, although an elevated suspicion was warranted at the time of admission. His subsequent workup while inpatient was appropriately thorough and well-documented, and he was discharged in improved condition. 

The insurer's denial of coverage for the inpatient is overturned. Medical Necessity is substantiated.