Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left sided pneumonia
Treatment: Inpatient admission  
The insurer denied coverage for: Inpatient admission.
The denial is: Upheld.
The patient was having trouble breathing and shortness of breath (SOB). There is a past medical history of an episode of bronchiolitis. The patient had a one-day history of a fever and a cough. The child had immigrated to New York from Ecuador one month prior to this illness. The mother brought the patient to the Emergency Room (ER) when the patient was noted to have a decrease in oral fluid intake and difficulty breathing. The patient was treated with nebulized Duoneb, Prednisone and one dose of Unasyn. A white blood cell count (WBC) was elevated at 23,000. A chest radiographic image (x-ray) was interpreted as showing a left sided pneumonia and cardiomegaly. The patient was started on 3 liters of oxygen (O2) supplementation and transferred to another hospital for ongoing care.

In the ER the patient was admitted to the inpatient hospital service while awaiting a bed. The patient was weaned off oxygen and was found to be breathing comfortably with no increased work of breathing. The oxygen saturation off oxygen was 98%. A respiratory viral panel was negative. The patient was noted to be tolerating oral fluids and there was no need for placement of an intravenous line (IV) to administer fluids. On physical examination the patient was not in distress, some crackles over the left lung field on auscultation of the lung were noted.  A chest x-ray did not show cardiomegaly but there was evidence of left lower lobe pneumonia and a possible small pleural effusion. A chest ultrasound was then performed in the ER which did not demonstrate a pleural effusion but documented pneumonia. The child was reevaluated, and the decision was made to discharge the patient on Amoxicillin for 7 days to treat the pneumonia with a follow-up visit with the pediatrician recommended in 24-48 hours.
 
The child was discharged on the same day of the transfer to the second hospital. The insurer has denied coverage for acute inpatient admission to the hospital.

The patient was diagnosed with a pneumonia and cardiomegaly at the Emergency Room (ER) at, and the patient was transferred for admission on 3 liters of oxygen. When the child arrived in the ER the patient was weaned off oxygen since the oxygen saturation on room air was 98%. The patient was clinically stable and not in any respiratory distress. A decision was made that the patient did not require an IV because the patient was tolerating liquids by mouth. After testing in the ER which confirmed pneumonia and ruling out cardiomegaly and a pleural effusion the decision was made that the patient was stable enough to be discharged on oral antibiotics for 7 days with a follow-up with their pediatrician. 

The decision to admit the child to the inpatient service while still being evaluated in the ER was not consistent with the standard of care and the admission was not medically necessary. 

Based upon my review of the medical record the admission to the hospital was not medically necessary and the patient was safely discharged with continued treatment in the home and appropriate follow-up.

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 inpatient hospital stay is not substantiated.