Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-Pneumonia
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient is an infant with a medical history significant for transient tachypnea of the newborn that presented to the emergency department with a two-day history of cough, runny nose, and retractions. There was recent exposure to Covid (Coronavirus Disease) 19. Vital signs included temperature 37.6, heart rate 162, respiratory rate 42, and saturation 100% (percent) in room air. Examination was significant for respiratory distress with subcostal retractions. Rapid testing for respiratory syncytial virus (RSV), influenza, and Covid was negative. Chest x-ray revealed extensive consolidation of the right upper lobe. He was given a dose of ceftriaxone. Admitting diagnosis was likely viral pneumonia, less likely bacterial pneumonia. 

The acute inpatient admission was medically necessary for this young infant that presented with respiratory symptoms and had an x-ray positive for extensive consolidation by official radiology report.
Pneumonia occurs because 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 Chlamydophile pneumoniae are the most common bacterial pathogens of children and adolescents. Other bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Viral pathogens include RSV 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. Clinically, pneumonia is typically 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 infant presented with worsening cough and retractions as well as an episode of vomiting. Evaluation revealed an extensive right upper lobe consolidation. In an infant of this age, late-onset group B strep (GBS) infection as well as other bacterial and numerous viral infections may result in pneumonia, all with potential for serious sequelae such as acute respiratory failure. While the infant did not have an immediate need for supplemental oxygen and was feeding well, it was reasonable and appropriate to monitor in the hospital pending cultures to determine the trajectory of the illness and establish a reasonable course of therapy.  The entirety of the admission was medically necessary as an acute inpatient admission.