Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a female with history of asthma, hypertension (HTN), rheumatoid arthritis (RA), fibromyalgia and depression. The patient was recently treated for gastroenteritis and possible pneumonia when she was on vacation. On her return the patient started complaining of some productive cough again along with shortness of breath (SOB) and wheezing. The patient also complained of subjective fever and chills along with fatigue. The patient presented to the Emergency Department (ED), the patient's vital signs at presentation were temperature (T) 98.3 F, respiratory rate (RR) 18, heart rate (HR) 108, blood pressure (BP) 135/75 and oxygen (O2) saturations 96 % on room air. The patient was treated with steroids, bronchodilators and antibiotics. The patient had chest x-ray which revealed patchy right-sided infiltrate which was consistent with pneumonia. The patient's influenza screen was positive. 

The patient was transferred to another hospital for admission.  The patient's vital signs were: Temperature 98.4 F, Heart Rate 108, Blood Pressure 135/75 and Oxygen (O2) Saturations 96 % on room air (RA). The patient was in no acute distress (NAD). The patient was speaking in full sentences. The patient's lung exam revealed good air entry bilateral with bilateral wheezing. The patient's cardiac exam was unremarkable. The patient's abdominal exam was soft and non-tender (NT). The patient was alert and oriented. The patient's bloodwork showed: white blood cell (WBC) count 5.2 K, hemoglobin (Hb) 12.5, BUN/Creatinine 19/0.6, and the patient's electrolytes were within normal limits (WNL). The patient's chest x-ray showed patchy opacity of the right lung. The patient was treated with Duonebs, Tamiflu, ceftriaxone, oral azithromycin, and steroids. The patient remained stable after admission. The patient remained afebrile and hemodynamically stable. The patient was not hypoxic and was tolerating oral intake. This patient was discharged on oral medications.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient was afebrile and hemodynamically stable. The patient was not hypoxic and did not require supplemental oxygen. The patient's white blood cell (WBC) count and electrolytes were within normal limits. The patient's BUN/Creatinine labs were within normal limits (WNL). The patient's Pneumonia Severity, CURB 65 score was zero. The patient's asthma was also mild. The patient was in no acute distress. No respiratory distress was noted. The patient was speaking in full sentences. The patient had some wheezing bilaterally but was not hypoxic and was able to tolerate oral intake. The patient was on prednisone, Singulair, nebs and antibiotics for treatment. The patient was stable to be switched to oral antibiotics and could have been discharged on oral medications with close follow-up in an outpatient setting. The patient did not need acute hospitalization. The patient could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient could have then discharged home on oral medications after a period of observation in the Observational level of care.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.