Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-Pneumonia
Treatment: Inpatient Stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination for the dates in question.

The patient has a past medical history remarkable for breast cancer, stage III colon cancer, and COVID 19, and was admitted to the hospital. There were reports of dysphagia and dystonia.

The records were notable for a hospital admission for hypoxemic respiratory failure requiring prolonged ventilation and tracheostomy. The hospital course was remarkable for COVID pneumonia, severe adult respiratory distress syndrome (ARDS), urinary tract infection, severe malnutrition, hospital acquired pneumonia, psoas muscle hematoma, and treatment of persistent abscess with placement of an Interventional Radiology (IR) drain. The patient was admitted now for dysphagia. The patient was noted to have severe malnutrition due to malignancy, poor oral intake, and severely decreased energy intake of less than (<) 50% of energy requirements. The dysphagia was thought to be related to vocal cord paralysis given recent intubation and tracheostomy. The patient was treated with intravenous (IV) fluids and tube feeding via a nasogastric (NG) tube. The patient was treated for klebsiella urinary tract infection (UTI), wound care for an unstageable coccygeal ulcer, chronic respiratory failure with increase in oxygen requirements. The patient's oxygen saturation was noted to decrease to 88-92% (percent) with activity and without supplemental oxygen. The patient consistently required 35% (percent) (fraction of inspired oxygen) FIO2 to maintain normal oxygen saturation. The medical necessity of the inpatient stay for the dates in question is at issue. 

The requested health service/treatment of inpatient hospital admission was medically necessary.
The patient was admitted for acute on chronic respiratory failure and required supplemental oxygen to maintain oxygen saturation greater than (>)92% (percent). This was in the setting of multiple comorbid conditions (chronic respiratory failure, pneumonia, severe malnutrition) that placed the patient at risk for adverse outcomes and complications. Furthermore, the patient was hypoxic and was at risk for aspiration and further respiratory decompensation given the presence of tracheostomy.
Although the patient had healthcare acquired pneumonia, there are mortality tools for predicting the severity of pneumonia that are used in clinical practice. The Pneumonia severity index (PSI) is an important scoring system that can assess the severity of community acquired pneumonia (CAP) and can determine admission status. In this case, the patient's PSI is calculated as 105 points which represents Class IV with 8.2-9.3% (percent) mortality. The PSI score is mainly used for community acquired pneumonia and not necessarily healthcare acquired pneumonia. Based on the scoring, clinical judgement is required for the decision to admit a patient. The documentation supports inpatient admission for acute hypoxia with the need for supplemental oxygen via tracheostomy. Additionally, the presence of comorbid condition such as cancer, chronic respiratory failure, and tracheostomy portend an aspiration risk for this patient. The patient required inpatient admission for a swallow evaluation, IV antibiotics and IV fluids, and supplemental oxygen for hypoxia. The care could not have been safely rendered at a lower level of care.