Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever; cough
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male who presents to the emergency room with complaints of fever, nasal congestion and cough.  Medical history was significant for recent laparoscopic appendectomy.  The patient reported abdominal pain which he described as "hot and cold" sensation in the surgical site.  He denies sick contacts, recent travel chest pain or shortness of breath.

Emergency room vitals: temperature 98.1 F, heart rate 85 bpm, respiratory (breaths/min) 18, BP systolic 103mmHg, BP diastolic 68 mmHg, SpO2 (%) 99 on room air. 

Examination was notable for tenderness to palpation in the right lower quadrant, left lower quadrant as well as involuntary guarding; there was an area of cluster of lesions with ulcerated base on genitourinary exam.  Surgical site was clean.  The rest of the examination was grossly unremarkable. 

Laboratory studies: CO2 22 (normal 23-30), Ca 8.8 (normal 9.2-11), anion gap 17 (normal 0-10), lipase 62 (normal 20-51), normal CBC with differential. CT of the abdomen and pelvis showed mesenteric adenitis with adenopathy in the porta hepatis, hepatomegaly and hepatic steatosis; there was no evidence of appendicitis or acute obstructive process.  There were mild focal areas of sub segmental atelectasis in both lower lobes and both lung bases. Pleural effusions are not identified.  CXR showed right basilar pneumonia.

The admitting diagnose was hospital associated pneumonia.  Management plan included initiation of broad-spectrum antibiotics, blood and respiratory cultures, urine Legionella and urine drug screen.  

Progress note states, "Pt is comfortable, NAD. Afebrile. Clear lungs. No leukocytosis. CURB 65 score 0. Ambulating with no difficulty. Yelling at staff with no SOB. As per recent IDSA pneumonia guideline recent admission to the hospital is not an indication for MDRO treatment; pt is young and has no underlying lung disease. Will change treatment to cefuroxime and azithro (urine legionella negative; will order for 3 days)". 

Follow-up note states, "CT results most likely post-operative. No fever or WBC; will switch to po abx. if remains stable will dc in am. Has appointment with sx... " 

The patient was eventually discharged home on oral levofloxacin.

A critical essential step in effective management of pneumonia is deciding if patients can be safely managed as an outpatient. In some cases, admission to an observation unit, inpatient medical ward or higher acuity level of inpatient care is the best necessary step. Most physicians agree that the best approach for determining the level of care depends on the severity of illness, however other factors should be considered. Some of the factors include the ability to maintain oral intake, likelihood of medication adherence, history of active substance abuse, mental illness, cognitive or functional impairment, and living or social circumstances. 

There was no documentation that patient was unable to maintain oral intake, had problems with medication adherence, or had significant substance abuse that would impair outpatient treatment.  There was no documented significant mental illness, cognitive or functional impairments or difficult living conditions. 

Also, inpatient admission is suggested if the CURB-65 score is 2 or more.  In this case, the calculated CURB-65 score is 0, which places him at low risk group. 

The patient was hemodynamically stable without evidence of fever, sepsis or respiratory compromise.  Cardiopulmonary examination was benign.  His oxygen saturation was normal.  There was no significant electrolyte imbalance, leukocytosis, or anemia requiring blood transfusion.  

Inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.