Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever and cough.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

Yes, the inpatient admission was medically necessary.

The patient is a female child that presented to the ED for the fourth time with decreased intake, decreased wet diapers, and irritability. She had originally been seen in the ED about nine days prior because of fever to 101.6 and cough. She was diagnosed with viral upper respiratory infection and discharged home. She was drinking well at that time. Two days later, she was taken back to the ED because of poor intake. She was still febrile to 103.6 and continued coughing. She tolerated an oral trial in the ED, and was discharged home again with supportive treatment. She presented to the ED a third time with persistent fever to 102.6 and cough. She had already been seen by the pediatrician and diagnosed with influenza. She was taking Tamiflu and amoxicillin without improvement. She had decreased oral intake and decreased wet diapers. She was treated with normal saline bolus and evaluated for possible pneumonia. Influenza testing was negative. Chest x-ray revealed perihilar and basilar infiltrates. She was diagnosed with pneumonia and continued on amoxicillin with dose adjustment. She was discharged home to follow-up with her pediatrician. With each visit the family was given return precautions. 

On this fourth presentation to the ED, fever and cough had improved. Vital signs included temperature 37.2, heart rate 146, respiratory rate 52, and 97% oxygen saturation in room air. Examination revealed moderately dehydrated appearance. She was treated with a normal saline bolus. Chest x-ray revealed right lower lobe infiltrate consistent with pneumonia. She was admitted at this time for parenteral antibiotic therapy and hydration. She was given the first dose of ceftriaxone in the ED. Admission orders included normal saline nasal drops with bulb syringe as needed, intravenous (IV) fluids at maintenance, regular diet for age, continued treatment with ceftriaxone, and anti-pyretics. Overnight, she did well with no acute events. She tolerated fluids by mouth with good urine output. She remained afebrile but had had intermittent tachypnea. The etiology of her symptoms was ultimately determined to be viral in origin, with no plans for home antibiotics. She was able to wean from IV fluids over the course of the day and was deemed stable for discharge home.  

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 respiratory syncytial virus (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, abscess, or sepsis.

This patient presented to the ED for the fourth time after three visits to the ED and visits to the pediatrician, and was symptomatic while under treatment for influenza. While fever and cough had improved over the course of her outpatient management, she was irritable and not drinking well. She was moderately dehydrated on exam, requiring parenteral fluids. She was also found to have a right-sided infiltrate on chest x-ray with concerns for pneumonia, possibly secondary bacterial infection. Even though she had no oxygen requirement and was overall hemodynamically stable, she failed outpatient management over the course of multiple visits and appropriate outpatient treatment. This hospital stay was medically necessary and appropriate at an acute inpatient level of care.