Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Hospital Admission
The insurer denied: Hospital Admission
The denial is: Upheld

The patient is a male who presented to the hospital with complaints of chest tightness, fever, malaise, and diarrhea. His symptoms started one day before the presentation. He reported that his son was sick. After developing symptoms, he slept for 36 hours, then he woke up but still was not feeling very well, therefore decided to come to the hospital. The review of systems was negative for everything except for the symptoms listed above.

When the patient was seen by the admitting physician, he was afebrile. However, initially, in the emergency department, he had a fever of 39.1 Celsius (C). The blood pressure was 155/79, pulse rate 78 beats per minute (bpm), respiratory rate 15 breaths per minute, and oxygen saturation 95% on room air. The patient was morbidly obese. He was resting comfortably, in no acute distress, awake, alert, and oriented times 3. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. There was mild wheezing, but his respirations were nonlabored and inspiratory effort was appropriate. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.

The chest x-ray demonstrated the patient had a right lung base infiltrate, which was suspicious for early pneumonia.
The patient was admitted to the hospital with acute asthma exacerbation due to influenza versus dust exposure.
Another clinical problem was chest tightness; therefore, serial troponins were ordered. The list of secondary diagnoses included chronic kidney disease, prediabetes, and hypertension.
During the hospital stay, the patient was diagnosed with influenza A. He was started on Tamiflu. The repeat chest x-ray showed no acute pathology; therefore, the diagnosis of pneumonia was ruled out. His peak expiratory flow (PEF) remained in the 400s.
During the hospital stay, the patient demonstrated significant improvement in his symptoms. He remained hemodynamically stable.
He was discharged home the next day after the day of admission.

The health plan's determination is upheld.

The hospital admission was not medically necessary.
The review of medical records demonstrated that the services could have been provided at a lower level of care since neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.
The patient presented to the hospital with a fever and shortness of breath, which was possibly related to mild asthma exacerbation that was triggered by influenza A.
At the same time, his symptoms were relatively mild and responded quickly to treatment provided in the hospital.
There was no evidence of significant carbon dioxide (CO2) retention. It was clearly indicated that the peak expiratory flow was in the 400s. There was no evidence of severe respiratory compromise in the form of hypoxemia or altered mental status.
Pneumonia, which was initially suspected at the time of admission, was ruled out by the second chest x-ray.
There was no mention that the patient had other respiratory symptoms including stridor, gross hemoptysis, or acute cyanosis.
Overall, the patient's clinical condition improved very quickly, and the patient was discharged from the hospital the next day after the day of admission.