Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female.  The service under review is inpatient hospital admission.  This service was denied as not medically necessary and this decision is being appealed.

The patient presented to the emergency department with wheeze, retractions, and cold symptoms.  Her temperature was 98.8-100.9 degrees Fahrenheit (F), her heart rate was 147-151, her respiratory rate was 29-32, and her oxygen saturation (SpO2) was 99-100%.  On exam, the patient was noted to have respiratory distress, suprasternal retractions, and bilateral wheeze.  Her chest x-ray showed right middle lobe pneumonia.  The patient was treated with three doses of nebulized albuterol plus ipratropium, intramuscular dexamethasone, and ceftriaxone.  She was admitted due to an inadequate response to treatment.

No, the proposed inpatient hospital admission was not medically necessary.
This patient did not meet generally accepted practice guidelines.

Per the Pediatric Infectious Diseases Society - Infectious Diseases Society of America Pediatric Community-Acquired Pneumonia Severity Criteria (this guideline recommends care in an intensive care unit [ICU] or a unit with continuous cardiorespiratory monitoring if a child has one or more major or two or more minor criteria):

Major Criteria
- Invasive mechanical ventilation [Not met]
- Fluid refractory shock (Receipt of three or more isotonic fluid boluses) [Not met]
- Acute need for non-invasive positive pressure ventilation (receipt of high-flow nasal cannula, continuous positive airway pressure, bilevel positive airway pressure, or bag valve mask ventilation) [Not met]
- Hypoxemia requires a fraction of inspired oxygen (FiO2) greater than inspired concentration or flow feasible in general care area (use of aerosol or nonrebreather mask oxygen with a documented oxygen saturation of less than 92%) [Not met]

Minor Criteria
- Respiratory rate higher than World Health Organization classification for age (50 or more in children two to 12 months old, 40 or more in children 12 months to five years old) [Not met]
- Apnea [Not met]
- Increased work of breathing (presence of retractions, dyspnea, flaring, grunting, or increased work of breathing documented by a clinician) [Criteria met]
- Partial pressure of oxygen (PaO2): fraction of inspired oxygen (FiO2) ratio less than 250 (arterial blood gases are not routinely measured; therefore, serum pressure of oxygen (SpO2): fraction of inspired oxygen (FiO2) was used as a proxy. A serum pressure of oxygen (SpO2): fraction of inspired oxygen (FiO2) of less than 231 correlates with a partial pressure of oxygen (PaO2): fraction of inspired oxygen (FiO2) of less than 250) [Not met]
- Multilobar infiltrates (resent if there were infiltrates, opacities, or consolidations noted in more than one lobe on chest radiograph on the official radiology report) [Not met]
- Pediatric early warning score greater than six  [Not met, this patient's score was two.]
- Altered mental status (present if "altered mental status," "sleeping and not arousable," "lethargic," or "obtunded" were documented by a clinician) [Not met]
- Hypotension (defined as a systolic blood pressure less than the fifth percentile for age) [Not met]
- Presence of effusion [Not met]
- Comorbid conditions (eg, sickle cell disease, immunosuppression, immunodeficiency) [Not met]
- Unexplained metabolic acidosis (carbon dioxide [CO2] of 15 on a chemistry panel or potential of hydrogen (pH) less than 7.35 with bicarbonate (HCO3) less than 15 or a base deficit five on a blood gas) [Not met]

Although the patient had increased work of breathing noted, the patient did not meet the generally accepted criteria for inpatient hospital admission as none of the other criteria were met.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient
This patient did not meet generally accepted practice guidelines.