Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient is a male with history of renal transplant 15 years prior, on Tacrolimus and Mycophenolate, hypertension (HTN), hyperlipemia (HLD), diabetes mellitus 2 (DM2) on Metformin and his hemoglobin A1C (HgbA1C) was 8.9. He presented to the emergency department (ED) with complaints of (c/o) 3 days of weakness, generalized fatigue, headache, right ear pain and cough. He had initially been seen in an urgent care center earlier that day, and was advised to go to ED.

According to the infectious disease (ID) consult note, the patient reported not taking his immunosuppressants for several days due to not feeling well. His temperature was 101.6, he had tachycardia at a rate of 117, his respiratory rate (RR) was 22, his blood pressure (BP) was 150/98, and his room air (RA) oxygen saturation was 96 percent (%). His white blood cell count (WBC) was 20.7 with 80% polymorphonuclear white blood cells, 5% band neutrophils, his creatinine was 1.75 (baseline creatinine was noted as 1-1.2), and his lactate was1.9. The computed tomography (CT) of the patient's head (without contrast) was unremarkable. The patient's chest x-ray (CXR) showed a left lower lobe (LLL) hazy opacity. A rapid strep test was negative and the Coronavirus (COVID) test was also negative. He was admitted with a diagnosis of sepsis and pneumonia and the patient was started on Cefepime and Azithromycin. The patient was afebrile and his WBC was down to 14.5. He was discharged home on oral antibiotics.

The health plan, in its determination of medical necessity, acted reasonably and with sound medical judgement and in the best interest of this patient. The patient has history of a remote renal transplant, and is on immunosuppressants (though he had not been taking them for some days due to feeling ill), and met sepsis criteria on presentation, he was not hypoxic, he did not have an altered mental status, he did not require supplemental oxygen, he defervesced quickly, he remained hemodynamically stable throughout, and his laboratory derangements (AKI, leukocytosis) quickly trended down on IV fluids and antibiotic therapy, and he was not bacteremic, the patient's blood cultures were negative.

The patient was seen by ID and was diagnosed with community acquired pneumonia (CAP). The additional testing that was ordered was a urine streptococcus and urine legionella and Mycoplasma and Chlamydia serologies. It was advised that the patient continue with Cefepime and Azithromycin. Nephrology was consulted and advised to continue the Tacrolimus and to hold the Mycophenolate. The patient clinically improved, and his acute kidney injury (AKI) resolved, his creatinine came down to 0.87 after intravenous (IV) fluids. The patient's urine and blood cultures had no growth.

His confusion, uremia, respiratory rate, blood pressure, age greater than 65 years (CURB-65) score was equal to 1 and his pneumonia severity index (PORT/PSI) scoring also places him in low-risk category.

The health plan considers a full inpatient admission medically necessary when there is hypotension, confusion, sepsis with bacteremia, hypoxia/respiratory distress, failure of initial therapy. The patient responded quickly to the therapy provided, and his care could have been safely and appropriately provided at an alternate level of care.