Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; Pneumonia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This female patient has a history of congenital heart disease, possible ventricular septal defect status post repair in infancy.  The patient presented to the Emergency Department (ED) with complaints of an episode of shortness of breath while climbing stairs and some retrosternal chest pain. The patient denied any fever or chills. The patient also reported symptoms of upper respiratory tract infection 3 weeks ago for which she was seen at an urgent care center and was treated with some steroids. In the ED, the patient's vital signs were: temperature 98, respiratory rate 16, heart rate 100, blood pressure 142/99 mm Hg, and oxygen saturation of 98% on room air.  On exam, the patient was noted to be not in acute distress, and the physical exam was unremarkable. The patient's lab showed: white blood cell (WBC) count 10.4, hemoglobin 11.4, sodium 134, troponin 0.01, pro-BNP 448 (normal <450), BUN/Cr 12/0.6, and normal CPK and electrolytes. The patient's chest x-ray revealed some patchy left medial zone and left lower zone air space disease. The patient's differential diagnosis included pneumonia, consolidative process or mild edema. The patient was admitted and was started on Rocephin and azithromycin. As per the history and physical note, the patient's vital signs remained stable with temperature of 98.1, heart rate of 79, blood pressure of 133/81, respiratory rate of 18 and oxygen saturation of 95% on room air. The patient's physical exam was unremarkable. The patient was in no acute distress, and had clear lungs and no edema. The patient was awake and alert with a non-focal neuro exam, and a normal cardiovascular and abdominal exam. This patient underwent a computed tomography angiography (CTA) which was negative for pulmonary embolism (PE); there were scattered patchy opacities throughout the left lung compatible with unilateral pulmonary edema or pneumonia, and a clear right lung. The patient's follow-up CPK and troponin labs remained negative. The patient's electrocardiogram (EKG) did not reveal any ischemic changes. The patient had 1 degree AV-block.  The patient's urine antigen testing for Legionella and Streptococcus was negative. The patient was seen by cardiology and an echocardiogram showed normal left ventricular ejection fraction (LVEF) of 60%. The cardiologist's impression was that this patient's chest pain was atypical and likely related to her pneumonia, and further follow up was recommended in the outpatient setting.

Based on the review of the medical record and literature, this patient's clinical presentation did not require acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was afebrile and hemodynamically stable. The patient remained afebrile and hemodynamically stable even after her admission and during her inpatient stay. The concern for myocardial infarction (MI) was ruled out. The patient's pneumonia was consistent with atypical pneumonia, and was mild in severity. The patient's pneumonia severity, CURB 65 score was zero. The patient was not hypoxic, and her white blood cell (WBC) count was within normal limits. The patient was tolerating oral intake. As per cardiology consult, no inpatient intervention was recommended, and the plan was for the patient to follow-up as outpatient. This patient could have been discharged home after a period in observation on oral antibiotic and maintenance medications with close follow-up in outpatient setting. 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 inpatient admission is not substantiated.  The insurer's denial should be upheld.