Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Respiratory System
Treatment: Inpatient hospital stay

Diagnosis: Respiratory System-Pneumonia
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay as not medically necessary. The denial was upheld in whole.

The patient has a past medical history significant for type II diabetes mellitus, coronary artery disease, hyperlipidemia, gastroesophageal reflux disease (GERD), peptic ulcer disease, stage IV sacral ulcer, bipolar disorder, sciatica, and asthma who presented to the emergency department according to the recommendations of her primary care physician.
Reportedly, the patient went to see the primary care physician because of cough, and underwent lab work that demonstrated  serum potassium was 6.4. Because of the possible hyperkalemia, the patient was referred to the emergency department. The patient complained of a productive cough, dysuria, increased frequency of urination, urgency, and pelvic pain. The initial basic metabolic profile performed  showed that serum sodium was 136, potassium 5.2, chloride 100, bicarbonate 20, blood urea nitrogen (BUN) 54, creatinine 2.04, glucose 106. a renal ultrasound that did not show any acute abnormalities. The patient was admitted to the hospital with a diagnosis of acute kidney injury and urinary tract infection, hyperkalemia. The patient was started on intravenous fluids.
Another clinical diagnosis was cough, which was attributed to pneumonia vs. MAC. The patient was started on nebulizers, azithromycin, received supportive treatment with Robitussin. Because of the history of pulmonary embolism, the patient was continued on home regimen of Apixaban. The urine culture came back positive for Klebsiella, the patient was switched to oral antibiotics to complete the course of treatment as an outpatient and was discharged home.

In order to make a decision if the admission was really required at the acute inpatient level of care, I referred to the CURB-65 Score for pneumonia severity. This is a risk stratification tool that estimates the mortality of community-acquired pneumonia and helps to determine the need for inpatient care vs. outpatient treatment. Based on the calculations, this patient received 1 point for BUN being greater than 19 mg/dL, therefore she belonged to a low-risk group with 2.7% 30-day mortality. Patients who belong to the low-risk group are usually recommended outpatient treatment of pneumonia.
Another clinical problem was acute kidney injury and mild hyperkalemia. This clinical problem resolved fairly quickly. On the next day after the day of admission, the patient's creatinine was almost normal. It completely normalized within the first 48 hours of admission. Even though the kidney function was abnormal at the time of admission, the patient did not have any clinical signs of uremia.
Although the patient had urinary tract infection and the review of systems obtained at the time of admission was positive for dysuria, increased frequency of urination, and urgency and pelvic pain, the patient could have received treatment with oral antibiotics. There were no reports of intractable nausea or vomiting that would preclude her from taking oral antibiotics.
Taking into consideration all these facts, it was appropriate to admit the patient at a lower level of care to provide treatment with intravenous fluids and monitor kidney function, and at the same time treat the urinary tract infection and pneumonia. However, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.