Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza, Asthma exacerbation, Possible pneumonia

Treatment: Acute inpatient admission

The insurer denied coverage for the acute inpatient admission.

The denial is upheld.

This is a male patient with a history of obesity, hypertension, and asthma. The patient had been seen in the Urgent Care and was diagnosed to have Influenza; he was discharged home on Tamiflu. The patient reported that he did not feel much better after 2 days so he went to the Emergency Department (ED). The patient presented to the hospital with complaints of shortness of breath, wheezing and fever for 3 days.

The patient's vital signs at presentation to the ED were: blood pressure 119/70, heart rate 95, temperature 99.3, respiratory rate 18, and oxygen saturation 93% on room air. On exam, the patient was in no acute distress and his lungs revealed some decreased air entry with bilateral wheezing. The patient's bloodwork showed: white blood cell (WBC) count of 12.9, hemoglobin of 14.8, sodium of 133, blood urea nitrogen (BUN) and creatinine of 14 and 0.9, and lactate of 2.8. The patient's chest X-ray showed mild right basilar infiltrate and retrocardiac left lower lobe infiltrate. The impression was bibasilar lung infiltrates which were suspicious for pneumonia. The patient was treated with intravenous (IV) fluids, bronchodilators, steroids, IV antibiotics (i.e., Rocephin and azithromycin), and Tamiflu. The patient's repeat influenza test in the ED was positive. The patient was admitted to the hospital with diagnosis of influenza, asthma exacerbation and possible pneumonia. The patient was treated and clinically improved after hospitalization. The patient was tolerating oral intake and was subsequently discharged home on oral antibiotics and maintenance medications. 

Based on the review of the medical record and literature, the patient did not need acute hospitalization. The patient could have been placed on Observation status while diagnostic testing and treatment was initiated. The patient clinically improved. The patient reported feeling better, and was tolerating oral intake. The patient was also afebrile and had stable vitals (i.e., blood pressure 105/62, respiratory rate 20, heart rate 56, and oxygen saturation 94% on room air). The patient's lung exam showed mild wheezes and some rales. The patient's white blood cell (WBC) was mildly elevated likely due to steroid effect. The patient's lactate was also mildly increased which could have been due to his beta-agonist medication. The patient's pneumonia severity score was 0. The patient had a mild asthma exacerbation in the setting of an influenza infection that improved with bronchodilators and steroids. As per infectious disease (ID) consultation, they recommended transitioning the patient to oral antibiotics and early discharge. 

This patient was stable to be placed in Observation status for 24 to 48 hours and subsequently be discharged home on oral medications once he improved. As per records, the patient clinically improved by day 3 of presentation to the hospital. The patient was stable for discharge on oral antibiotics, steroids, bronchodilators and maintenance medications with close follow-up as outpatient. The patient has not trialed and failed Observation level of care. Thus, inpatient admission was not medically necessary for this patient.  

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the acute inpatient admission is not substantiated. The insurer's denial should be upheld.