Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who initially presented to the emergency department with concerns of speech changes. His pertinent history included alcohol use and cannabis ingestion a few hours before the presenting symptoms. The additional history included diabetes mellitus and hypertension.  Computed tomography angiography (CTA) of the Brain/Neck were unremarkable. CTA of the chest revealed a patchy infiltrate posteriorly at the right lung base, but no pulmonary embolism. Infectious disease consulted and had an impression of questionable aspiration with no signs or symptoms to suggest such. Pulmonary consulted, noted an oxygen saturation of 96 percent (%) on room air with right base pneumonia, and agreed with empiric antibiotics.  At issue is the medical necessity of an inpatient stay. Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

Clinical indications for acute inpatient level of care were not met. The patient did not have hemodynamic instability, dangerous arrhythmia, potential for dangerous arrhythmia , tachypnea that persists despite observation care treatment, hypoxemia, hypertension requiring inpatient treatment, severe electrolyte abnormalities requiring inpatient care, specific finding indicating severe, prolonged or delayed drug toxicity (eg, recurrent respiratory depression, persistent neurologic abnormalities), persistent altered mental status, metabolic finding (eg, metabolic acidosis) that is too severe for observation care treatment or persists despite such, toxic drug level that is persistent or necessitates ongoing treatment (eg, acetaminophen, warfarin), new neurologic abnormality (seizures, focal deficit), intravenous infusion of sodium bicarbonate, anticoagulation, platelet inhibitor, vasoactive, or antiarrhythmic medication necessitating inpatient care, or psychiatric risk status not acceptable for outpatient management. The patient also did not have severe or persistent dehydration, ventilator assistance needed, bacteremia, CURB-65 [confusion of new onset, blood urea nitrogen greater than 7 millimoles per liter (mmol/L) (19 milligrams per deciliter (mg/dL)), respiratory rate of 30 breaths per minute or greater, blood pressure less than 90 millimeters of mercury (mmHg) systolic or diastolic blood pressure 60 mmHg or less, age 65 or older] score of 3 or greater, Pneumonia Severity Index (PSI) class IV or V, CURB-65 score of 2 who did not improve with observation care treatment, outpatient treatment failure, appropriate diagnostic testing and treatment unavailable in outpatient or recovery facility, respiratory findings (eg, tachypnea) that do not respond to observation care treatment, complicated pleural effusions (eg, empyema, exudative, loculated), immunocompromised patient, or insolation indicated that cannot be performed outside hospital setting[2][3]