Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is overturned. 

The patient is a male with a past medical history significant for human immunodeficiency virus (HIV), hypertension, end-stage renal disease on hemodialysis, syphilis, and polysubstance abuse who presented to the emergency department with complaints of cough, fever, and shortness of breath. The patient stated that the cough was productive of white sputum, sometimes mixed with blood. The patient denied chest pain but complained of a sore throat and runny nose. He stated that he had a fever, but no drenching night sweats. He stated that he had been tested for tuberculosis and had three negative tests. It was mentioned that the patient was seen for similar symptoms in the emergency department two days before the presentation and was found to have bilateral lower lobe pneumonia. At that time, he left the hospital against medical advice. Reportedly, he was still prescribed oral antibiotics, which he never picked up in the pharmacy.

Laboratory evaluation revealed that his white blood cell count was 5.5, hemoglobin was 11.7, hematocrit was 37.6, and platelets were 112. Sodium was 134, potassium was 7.4, chloride was 96, bicarbonate (HCO3) was 25, blood urea nitrogen (BUN) was 66, creatinine was 13.5, and glucose was 76. Liver function tests were unremarkable. Creatine phosphokinase (CPK) was normal. Chest x-ray revealed diffuse right greater than left infiltrate with slight worsening compared to the film performed prior to admission. He was seen by a nephrologist and underwent two hemodialysis sessions. As a result of the treatment, the patient's clinical condition significantly improved, and he was discharged from the hospital with a recommendation to follow up with his primary care physician as well as infectious disease specialist. The subject under review is the medical necessity for an inpatient hospital admission.

The health plan's determination is overturned.

It is a common clinical practice to admit the patient to the hospital at the acute inpatient level of care for treatment of community-acquired pneumonia when patients are immunocompromised.

In this clinical case, the patient was immunocompromised because of a long-standing history of HIV infection. He was also hemodialysis-dependent. The patient also had significant electrolyte abnormalities that were related to his end-stage renal disease that required hemodialysis.

Another serious issue that would complicate his adherence to outpatient treatment was medical noncompliance. It was clearly indicated that during the emergency department visit two days before the presentation, the patient had oral antibiotics prescribed for treatment of community-acquired pneumonia, which he never got from the pharmacy.

Moreover, the chest x-ray that was performed on the day of admission demonstrated worsening pulmonary infiltrates compared to the previous film that was done just two days before the day of admission, and that was suggestive of worsening pneumonia.

Taking into consideration all these facts, the admission at the acute inpatient level of care was medically necessary to treat pneumonia in a timely manner.