Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department with shortness of breath, a cough, and fever. She had recently been seen and diagnosed with influenza and pneumonia and treated with Tamiflu and augmentin without improvement.
On presentation, she was febrile to 100.5 degrees Fahrenheit (F), with normotension, with a respiratory rate of 20, and oxygen saturation of 95% on room air. The exam otherwise noted scattered ronchi and mild wheezes. Labs resulted with a white blood cell count (WBC) of 8.1, hemoglobin (HGB) 12, platelets 242, sodium 137, potassium 4.1, blood urea nitrogen (BUN) 30, creatinine 1.1, glucose 65, bicarbonate 18, and normal lactic acid. A chest x-ray showed right basilar consolidation. The patient was brought into the hospital with a concern for pneumonia and plans for intravenous (IV) antibiotics and nebulizers.
She was febrile to 100.5 degrees F with a respiratory rate of 20, heart rate 93, and with an oxygen saturation greater than (>) 90% on room air and with WBCs 10.8. The exam continued to note crackles on the right side. The plan remained the same with an additional plan to consider consulting the intensive care unit (ICU) team if she did not improve.
On 1/3, she was afebrile with normotension, RR 20, and oxygen saturation normal on room air. The WBCs increased to 12.8 and arterial blood gas (ABG) showed partial pressure of oxygen (pO2) of 62% on RA. She continued to have poor air exchange on exam, was toxic appearing, and had crackles over the right lung. A repeat chest x-ray showed ongoing right lower lobe infiltrate without improvement. Given worsening, a consult was made to the intensive care unit (ICU) to evaluate the patient. Infectious disease recommended IV vancomycin given the high risk for MRSA pneumonia with influenza and was concerned about possible necrotizing pneumonia given her toxic appearance, increasing white blood cell count, and failure to improve, with a chest computed tomography (CT) scan also recommended. Despite a strong recommendation that the patient stay, she subsequently left against medical advice.
The issue for review is whether an inpatient stay was medically necessary.
Inpatient stay was medically necessary for this patient. This is a patient who presented with pneumonia in the setting of recent diagnosis of influenza who had failed outpatient therapy with augmentin and Tamiflu and had ongoing symptoms with abnormal respiratory exam and imaging evidence of pneumonia. She was at high risk for MRSA infection given the increased incidence of MRSA in the setting of influenza, and there was concern as well from the infectious disease consultant on 1/3 that given her failure to respond to outpatient therapies and inpatient IV antibiotics that she may have developed a necrotizing infection. Though her hospitalization was only 48 hours, this was in the context of her leaving against medical advice and clear concern that she had continued to fail to improve with a CT scan recommended by infectious disease in addition to ongoing IV antibiotics. This patient, presenting with pneumonia at high risk of MRSA who had failed outpatient therapy with Augmentin and Tamfilu and subsequently failed to improve with 48 hours of inpatient therapies and for whom there was concern for development of necrotizing pneumonia, was appropriate for an inpatient level of care.