Appeal type: Medical necessity
Decision: Upheld

This is a case of a male, with no major medical problems, who presented to the emergency department with a one-week history of significant coughing with associated shortness of breath and fevers. The patient has a history of tobacco use as well as marijuana use. The patient also reported nausea vomiting and diarrhea for 7 days. He used Advil, to try to relieve symptoms, without significant success. On physical exam, the temperature is 102.7, the pulse was 115, blood pressure 116/57 and the respirations were 15. The patient's oxygen saturation was 95% on room air. On the lung exam, the patient has no use of accessory muscles, has some tenderness to the right lower quadrant on the exam.
Arterial blood gas (ABG) was done on admission, which showed a pH of 7.37, partial pressure of carbon dioxide (PCO2) of 46, partial pressure of oxygen (PO2) of 71 and bicarb level of 26.6. Laboratory studies reveal a white blood cell count of 8000, hemoglobin of 12.8. The creatinine was 1.05, sodium slightly low at 134, chloride low at 94. Liver function tests (LFTs) were normal. Influenza A and B polymerase chain reactions (PCRs) were negative. The lactate was 0.9. The tox screen was positive for cannabinoids. Urinalysis was negative for urinary tract infection. The patient had a chest x-ray, which showed bilateral infiltrates, most prominent in the lower lobes, concerning for pneumonia. Computed tomography (CT) scan of the abdomen and pelvis with contrast was done, which showed the lung bases demonstrating diffuse bilateral infiltrates. The rest of the exam was normal. The patient was given early goal-directed therapy with saline, Zofran for nausea and Pepcid. Repeat vital signs after treatment, showed a low-grade temperature of 100.7, a pulse of 100, respiratory rate of 20 and blood pressure remaining low at 98/50.
An additional liter of fluid was given, and the patient was started on IV Rocephin and IV azithromycin. Blood pressure remained borderline low with 96/56 at repeat vital signs.
At this point, the patient was admitted to the hospital for further evaluation and management.
The patient was admitted by the general medicine team, he admitted to vaping, marijuana use and tobacco use. This raised the concern, for vaping induced lung injury as well as severe pneumonia. IV fluids were continued due to hyponatremia. Based on the results of the ABG, which shows a slight elevation of the PCO2, bi-level positive airway pressure (BiPAP) was started on the patient.
The patient was evaluated by pulmonary medicine the following day and noted, a T-max of 102.7, blood pressure of 116/65 with a pulse of 103 and respirations 20. The patient at this time was on room air 98%. He was able to speak in full sentences but appeared anxious. The patient ambulated around the hallways, with apparent dyspnea on exertion. They were able to obtain a sputum sample that appeared green and blood-tinged. The chest was clear anteriorly, there were no wheezes or rales per the physical exam. The pulmonology team recommended respiratory therapy treatments and continuing the course of antibiotics. The patient was encouraged to ambulate and was able to accomplish independent ambulation. Antibiotics were switched to oral, and at this point, he was cleared for discharge to home.
The issue at hand is whether the above presentation warranted an inpatient level of care.

The health plan's determination is upheld.

Inpatient medical stay is not medically necessary for the patient, based on the provided documentation. The patient's calculated CURB 65 and pneumonia severity index scores, placed the patient in the low-risk category of risk for pneumonia. The studies of patients with scores this low demonstrate very low mortality. Typically, these cases are referred to outpatient treatment, however, this patient did satisfy systemic inflammatory response syndrome (SIRS) criteria on admission. The patient received appropriate treatment with IV fluids and IV antibiotics. Fortunately, his white blood cell count was normal. He was mounting a strong immune response, as evidenced by the elevated fevers. The patient did not have a PO2 of less than 60 to qualify for acute hypoxic respiratory failure. The PCO2 of 46, is not high enough, to qualify as acute hypercapnic respiratory failure, given that the pH remained normal the patient was rapidly weaned off oxygen. He did have some dyspnea on exertion while ambulating on room air, which is not unexpected with pneumonia. Overall, this is a young patient, who unfortunately uses marijuana and vaping devices, which likely caused bibasilar pneumonia. There is no evidence of severe lung injury or persistent hypoxemia. The patient is not showing signs of true sepsis. The lactate was normal.
In conclusion, the patient could have been treated at a lower level of care status but did not reach severity for inpatient level of care.