Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mycoplasma pneumonia.
Treatment: Acute inpatient admission.
The insurer denied coverage for the acute inpatient admission.
The denial is upheld. 

This is a female patient with a questionable history of asthma who presented to the emergency department (ED) with complaints of dry cough and shortness of breath for 2 weeks. The patient denied any fever or chest pain or palpitations. She reported that her symptoms became worse after doing some household chores. The patient took albuterol inhaler and nebulizers multiple times at home and as she did not feel better she presented to the ED via Emergency medical services (EMS). EMS gave the patient oxygen, dexamethasone and Duonebs. They also placed her on continuous positive airway pressure (CPAP).

In the ED at presentation, the patient's vital signs were: temperature (T) 97.4, heart rate (HR) 118, blood pressure (BP) 159/94, respiratory rate (RR) 24, and oxygen (O2) saturations were 100%. The patient was on BiLevel Positive Airway Pressure (BIPAP). She was noted to have some labored breathing with use of accessory muscles. She was not able to speak in complete sentences. Physical examination revealed bilateral rhonchi and wheezes. The patient was treated with intravenous (IV) Steroids, magnesium, bronchodilators and inhaled corticosteroid-and-long-acting beta agonist (ICS-LABA). Initial Laboratory results were: white blood cell (WBC) 8.6, eosinophils 27%, arterial blood gases (ABG) 7.41/35/86/22 on 3 liters oxygen via nasal cannula. Chest X-ray revealed mild right lower lobe infiltrate. The patient was also given a dose of IV antibiotics.

As per history and physical the patient had improved after treatment in the ED. The patient's respiratory rate had come down to 19, heart rate was 94, and oxygen saturation was 100% on 3 liters oxygen. The patient was feeling better. Lung examination was described to have bilateral rales. The patient was initially off antibiotics but was later placed on azithromycin once mycoplasma titers came back positive. She was continued on Solumedrol every 6 hours, bronchodilators, Montelukast and ICS-LABA.

On day 2 of admission, the patient's vital signs were: T 98.5, HR 85, RR 20, BP 147/83, and O2 saturations were 96% on 3 liters oxygen. Lung examination revealed bilateral crackles. WBC was 16.8; however the patient was on steroids. Eosinophils had become 0%.

This patient did not need acute inpatient hospitalization. She could have been placed on Observation Status while diagnostic testing and treatment were initiated. This patient had responded to treatment in the ED and was taken off BIPAP after a few hours of treatment in ED. The patient was afebrile and hemodynamically stable, and was able to tolerate oral intake. WBC was normal. The next day the increase was secondary to steroids. Eosinophilia also resolved. The patient could have been switched to oral steroids and continued on bronchodilators and other medications. This patient's pneumonia was mild. Initial WBC was normal. The patient was oxygenating well on minimal oxygen. The patient was stable to be discharged on oral azithromycin for her mycoplasma pneumonia after a period in Observation which could have been up to 48 hours without needing inpatient hospitalization. This patient remained stable after admission and was stable for discharge after a period in observation on oral meds. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the acute inpatient admission is not substantiated. The insurer's denial is upheld.