Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient has a history of hypertension (HTN), depression post-traumatic stress disorder (PTSD), pancreatic cancer, breast cancer, and obstructive sleep apnea (OSA) on Continuous Positive Airway Pressure (CPAP). The patient presented to the Emergency Department (ED) with complaints of shortness of breath (SOB). Emergency Medical Services (EMS) treated the patient with DuoNeb and steroids on the way to the ED.

Vital signs on presentation were: Temperature 100.4 Fahrenheit, pulse 114, respiratory rate (RR) 26, blood pressure (BP) 157/94, oxygen saturation 98% on 8 liters of oxygen. The patient was placed on bilevel positive airway pressure (BIPAP). There was no jugular venous distention (JVD).  The patient was alert and oriented x3 (Person, place, time). Lung exam revealed some rhonchi.  The patient's cardiovascular exam revealed normal sinus1 (S1) and sinus2 (S2). The patient's white blood cell count (WBC) was 16.3k, hemoglobin (Hgb) 10.5, lactate 1.7, electrolytes within normal limits, blood urea nitrogen (BUN) 12, creatinine 0.54, and troponin was negative. The patient's liver function tests were mildly elevated.  A chest radiographic image (CXR) revealed left middle lobe and left lower lobe patchy airspace disease suggestive of a possible evolving pneumonia. The patient was treated with steroids, intravenous (IV) Rocephin and Azithromycin. The patient was initially on BiPAP and was switched to oxygen by nasal cannula.  

The patient was admitted to the hospital for pneumonia (PNA) with hypoxemic respiratory failure.  The patient was seen by Pulmonary in consult. The patient had improved significantly, and Pulmonary recommended to discontinue steroids and switching to oral antibiotics as the patient had improved with treatment. 

The patient was in no acute distress and was saturating well on room air. Lung sounds were clear bilaterally.  The patient's WBC was elevated to 23, likely due to steroid effect.  

The patient was subsequently switched to oral antibiotics and discharged the next day. This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient improved rapidly after initiation of treatment. By the next day, the patient was off oxygen. The patient remained afebrile and hemodynamically stable. The patient was tolerating oral intake and lung sounds were clear.  

This patient could have been in observation which could be for up to 48 hours.  During this time, treatment and testing could have been done.  The patient improved rapidly in 24 hours and could have been discharged home after a period in observation with close follow-up in the outpatient setting. The patient's PNA was mild.  The patient's CURB-65 (Confusion, Urea, Respiratory Rate, Blood Pressure, Age > 65) was about 1. The patient's Pneumonia Severity Index (PSI) score was low. The patient was safe to be discharged home after a period in observation.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission from is not substantiated.