Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a toddler male child with medical history significant for mild intermittent asthma, speech delay, and heart murmur pending cardiology evaluation that presented to the emergency department with one-week history of fevers treated with Tylenol, cough, congestion, rhinorrhea, diarrhea, post-tussive emesis, headache, decreased appetite, decreased energy, red eyes with watery discharge, and sore throat. His sister had similar symptoms. Vital signs included temperature 38.3, heart rate crying 177, respiratory rate 32, with 100% (percent) saturation in room air. Examination was significant for no acute distress, bilateral impacted cerumen, congestion with rhinorrhea, moist mucous membranes, clear oropharynx, normal conjunctivae, clear lungs without wheezing or crackles, heart murmur, benign abdomen, 
good perfusion, and non-focal neurologic exam. Labs were obtained, including exposure labs (human immunodeficiency virus [HIV], hepatitis C [HepC], hepatitis B virus [HBV]) due to biting the nurse starting his intravenous access (IV), and 
significant for white blood cell count 19.9 thousand (K) with 77 percent neutrophils, hemoglobin 10.3, platelets 406 thousand, sodium 131, carbon dioxide (CO2) 14, human immunodeficiency virus (HIV) non-reactive, hepatitis B virus (HBV) non-reactive, hepatitis C (HepC) non-reactive, negative respiratory pathogen panel, negative group A Strep screen, urinalysis with ketonuria and proteinuria, C-reactive protein 22.7, urine and blood cultures pending. Chest x-ray revealed bilateral lower lobe consolidation with left pleural effusion consistent with complicated multifocal pneumonia. The patient was treated with normal saline bolus, Tylenol, maintenance intravenous fluids, and ceftriaxone. The patient was admitted for further management of pneumonia. Admission orders included maintenance intravenous fluids, transition to ampicillin, Tylenol as needed, and trending labs. 
The patient did well overnight, was afebrile, with improved oral intake. He was deemed stable for discharge home to complete a course of treatment with amoxicillin, albuterol as needed, and 
close follow-up.

The acute inpatient admission was not medically necessary.

This young male child with asthma and positive ill contacts presented with week-long history of fevers, cough, constitutional symptoms, and cold symptoms. His chest x-ray was significant for multifocal pneumonia consistent with community-acquired pneumonia. Labs were significant for leukocytosis and elevated inflammatory markers, metabolic acidosis, and dehydration. He was treated with fluids and antibiotics and admitted for further management. While it was reasonable to monitor this child in the hospital for progression versus resolution of illness, he was overall hemodynamically stable with no need for supplemental oxygen, no evidence of status asthmaticus, and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.