Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a female child. She presented to the ED with several-day history of worsening cough and one-day history of fever. She initially had cold symptoms that resolved. She was noted to have increased breathing difficulty at night, gasping for air with heavy breathing, rattling sounds, and wheezing. The cough was described as wet and productive. Her appetite was poor. 

The patient's vital signs included temperature 36.6, heart rate 146, respiratory rate 20, and 95% oxygen saturation in room air. Examination was significant for no apparent distress, nasal congestion with drainage, rhonchi at bilateral lung bases, regular heart rate and rhythm, and non-focal neurologic exam. She was treated with nebulized albuterol and Zyrtec. 

Chest x-ray revealed right middle lobe infiltrate, prompting laboratory assessment. Laboratory studies were significant for normal WBC (white blood cell) count and differential, mild metabolic acidosis with CO2 (carbon dioxide) 19, and negative influenza screen. 

The patient was treated with ceftriaxone and admitted for ongoing management. Admission orders included IV fluids, nebulized albuterol, and ceftriaxone. She had no fevers and improved appetite. 

The patient was deemed stable for discharge home to complete a course of azithromycin and follow-up with her pediatrician.

Pneumonia occurs as a result of inflammation of lung tissue from either infectious or non-infectious causes. Infectious causes include bacteria, viruses, and fungi. Non-infectious causes include aspiration, hypersensitivity reactions, and drug- or radiation-induced pneumonitis. Streptococcal pneumoniae is the most common bacterial pathogen of infants and young children, while Mycoplasma pneumoniae and Chlamydophila pneumoniae are the most common bacterial pathogens of children and adolescents. Other bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Viral pathogens include RSV (respiratory syncytial virus) and influenza, as well as rhinovirus, human metapneumovirus, parainfluenza, and adenovirus. Bacterial pneumonia typically occurs when organisms from the respiratory tract colonize the trachea and then gain access to the lungs, although hematogenous spread is also possible. 

Different bacterial pathogens invade according to their own specific pathogenic processes. Viral pneumonia occurs from viral spread along the airways accompanied by direct injury to the tissues with subsequent airway obstruction. Typically, pneumonia is preceded by upper respiratory tract infection symptoms, including cough and runny nose. The type and degree of symptoms of lower respiratory tract infection depend upon the organisms and stage of illness.
 
Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis, and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema, abscess, or sepsis.

This young child presented with signs and symptoms consistent with lower respiratory tract infection, confirmed by the finding of bilateral infiltrates on chest x-ray. She reportedly had significantly increased work of breathing at home, particularly at night, but in the ED was in no apparent distress. Moreover, she had no hypoxia and no need for supplemental oxygen. While it was not unreasonable to monitor her in the hospital for a period of time for signs of decompensation, she was overall hemodynamically stable, with no evidence of impending respiratory failure, no signs of sepsis, and no significant dehydration. She did not require acute inpatient admission. She could have been safely managed at a lower level of care, such as observation.