Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, pneumonia, atypical acute coronary syndrome, and anemia
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an adult male with a past medical history significant for diabetes mellitus, pneumonia, atypical acute coronary syndrome (ACS), and anemia. The patient presented to the emergency department with complaints of fever for the past five days and abdominal pain for the past two days. The patient reported symptoms of fever, fatigue, cough, abdominal pain, light-headedness, weakness, myalgias, dry cough, and congestion. The patient's evaluation showed the following vitals: blood pressure (BP) 119/64, pulse 67, temperature 99.2 degrees Fahrenheit (37.3 degrees Celsius) (oral), respiratory rate 15, and oxygen saturation (SpO2) 94 percent. The patient's labs showed the following: white blood cell (WBC) count 14.1, sodium (Na) 129, and alkaline phosphate 387. Chest x-ray was reported as: "Right lower lobe opacity. Small right pleural effusion. Right upper lobe opacity with volume loss. Findings are consistent with multifocal severe pneumonia. Elective follow-up contrast - enhanced CT suggested." Computed tomography (CT) scan of the abdomen and pelvis was notable for the following findings: "LUNG BASES/PLEURA: Small right pleural effusion. Large area of right lower lobe consolidative opacity extending above the level of these images. This likely represents pneumonia. Trace left pleural effusion." The patient was evaluated by Infectious Diseases and was started on intravenous (IV) azithromycin and IV ceftriaxone. The patient was admitted for further management of pneumonia. 

The inpatient hospital admission was medically necessary.

This patient's clinical presentation and findings from the chest x-ray showed that patient had multifocal severe pneumonia and lab tests showed notable leukocytosis and hyponatremia. CT scan also confirmed the findings of pneumonia and effusion. Considering the severity of presentation and imaging findings, it could be reasonably expected that the patient would need several days of IV antibiotics to ensure that the patient is responding to treatment and to ensure that the response is adequate. This patient presented with symptoms concerning for pathology - either infectious or otherwise involving the lungs / abdomen - and work up in the emergency room/hospital stay showed that the patient had multifocal severe pneumonia. Additionally, admission labs were notable for high white blood cells/alkaline phosphatase (ALP)/alanine aminotransferase (ALT) and low sodium. CT scan findings confirmed the finding of large pneumonia. Considering the clinical presentation, findings of x-ray and CT of the chest. The patient was started on IV antibiotics upon presentation. For a patient with the above clinical presentation of multifocal pneumonia, inpatient admission is medically appropriate to ensure that the patient is adequately treated and also to confirm that the patient is responding to the treatment started. Inpatient admission allows the provider to make adjustments to treatment if the patient is not responding to treatment or to manage appropriately if the patient develops severe sepsis or respiratory compromise related to the diagnosis of multifocal severe pneumonia. Once admitted, such a patient may continue to improve on treatment and get discharged early (like this patient), or sometimes the patient may not improve - deteriorate and may need modification of treatment or addition of further treatment depending on the clinical course after admission. This patient presented with severe pneumonia and had risk factor of diabetes that would make it important to admit the patient to monitor and confirm response to treatment. In view of this, medical admission was medically appropriate.