Appeal type: Medical necessity
Decision: Overturned

The patient is a young previously healthy female brought to the accepting hospital from an outside hospital with a chest computed tomography (CT) scan that confirmed lower lobe pneumonia. She had a fever 102 on the day prior to presentation with associated cough, nasal congestion, right lower quadrant (RLQ) abdominal pain and one episode of emesis. She also appeared to be having difficulty breathing. The outside hospital did workups to include an abdominal ultrasound (US), CT abdomen and pelvis and chest x-ray (CXR) of which only the CT scan of the abdomen and pelvis showed a right lower lobe (RLL) consolidation. The admission exam documented a respiratory rate (RR) 24, and an O2 saturation of 98% on nasal cannula. She was described as sleeping comfortably in no distress, and her exam was pertinent for diminished breath sounds to the right lower-mid lung fields posteriorly. She was placed on intravenous fluids (IVF) and respiratory support with 2L of O2 via nasal cannula (NC) for persistent O2 saturations at 90%. She received intravenous (IV) Ceftriaxone x 2 and IV Azithromycin x 2 and was monitored. A complete blood count (CBC) and comprehensive metabolic panel (CMP) were done and were unremarkable except for a white blood cell count (WBC) of 15.9 at OSH. The following day, since she was doing well and no longer hypoxic on room air, she was considered safe for discharge with by mouth (PO) Amoxicillin for 10 days. Issue at hand is the medical necessity for the inpatient level of care. The health plan's determination of medical necessity is overturned. The health plan, it its determination of medical necessity, did not act reasonably, with sound medical judgment or in the best interest of the patient. This patient presented with fever, tachypnea and abdominal pain. She was found to have pneumonia evidenced by right lower lobe (RLL) consolidation as well as hypoxia requiring supplemental O2. After emergency room (ER) management she continued with tachypnea and failed a trial on room air. She was then transferred for admission. She would require close monitoring of her respiratory status as deterioration is a great risk in the event, she did not respond to the supplemental O2 and needed increased support. This patient was treated and monitored in the ER for 4 hours prior to the decision being made to transfer for admission. After arrival to accepting facility she had RR documented at 40 and heart rate (HR) at 134 in the absence of a fever. Close monitoring of her respiratory status and assessment of her response to antibiotic therapy as an inpatient is reasonable given her clinical presentation and persistent respiratory findings of hypoxia and tachypnea. Inpatient admission is recommended for pneumonia for those patients with hypoxia and tachypnea. She required close monitoring of her respiratory status as deterioration is a great risk in the event, she did not respond to the supplemental O2 and needed increased support. It has been noted that oxygen saturation is the most consistent clinical predictor of deterioration. The possible need for higher acuity of care once admitted is evidenced by oxygen requirement along with the need for respiratory monitoring at least every (Q) 4 hours. Continuous pulse oximetry and frequent respiratory assessment were needed to monitor her clinical status especially given the fact that she was requiring supplemental O2 to maintain her saturations. Surveillance as an inpatient is reasonable and necessary. Although she did have a rapid response to therapy, this cannot be foreseen at the outset. For this patient with hypoxia, tachypnea along with consolidation on CT the inpatient care was medically necessary.