Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/Pneumonia. 
Treatment: Inpatient Hospital Admission. 

The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns of fever and cough. Pertinent history included opiate use disorder, asthma, and prior endocarditis associated with intracerebral hemorrhage. Initial vital signs revealed a temperature of 102.4 (Fahrenheit) F., a heart rate (HR) of 101 beats per minute (bpm), a blood pressure (BP) of 117/71 millimeters of mercury (mmHg), a respiratory rate (RR) of 22/minute, and a peripheral capillary oxygen saturation (SpO2) of 92% on room air. Initial examination documented the patient as alert, oriented, and in no acute distress. Initial laboratory testing revealed a white blood cell count (WBC) of 9.8, a hemoglobin of 11.8, platelets of 141, a blood urea nitrogen (BUN) of 12, a creatinine of 0.96, a glucose of 98, a sodium of 138, and the Troponin was negative. Rapid viral testing was unremarkable. Urinalysis was unremarkable. A chest radiograph showed no evidence of focal pneumonia. Empiric antibiotics and corticosteroids were provided. The patient was placed in the hospital thereafter. The admitting physician had an impression of pneumonia and possible asthma exacerbation. The treatment plan included continued empiric antibiotics, Prednisone, and as needed bronchodilators. Infectious disease was consulted and had an impression of viral versus bacterial pneumonia. Recommendations were additional infectious evaluation and continuation of empiric antibiotics. The patient was documented as improved. There were no new issues or significant change in the treatment plan. The next day, the patient was discharged. 

At issue is the medical necessity for the inpatient hospital admission. 

The health plan's determination of medical necessity is upheld, in whole. 

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. 
The patient presented with concerns of fever and cough. Initial evaluation revealed a temperature of 102.4F., a RR 22/minute, a WBC of 9.8, a BUN of 12, and a chest radiography was negative for a consolidation or significant effusion. The CURB-65 score was 0, the CRB-65 score was 0, and the Pneumonia Severity Index (PSI) was a class of II. Treatment included empiric antibiotics. No pathogen was identified. No hypoxia was noted. Following observation care, the patient was improved. 

In patients with community acquired pneumonia (CAP), several scores have been developed to identify high-risk patients and support therapeutic decisions. Two of these scores, Confusion, Urea, Respiratory Rate, Blood Pressure and Age (CURB-65) and Pneumonia Severity Index (PSI), are well-validated scores to support CAP management and prognosis. Simplifications of CURB-65 (i.e., Confusion, Respiratory Rate and Blood Pressure CRB-65) have been developed and validated to facilitate the risk stratification process; these simplified scores do not require blood tests.[1] 

In this particular situation, the patient was low-risk and had a score that indicated safe management at an alternate level of care. Moreover, clinical indications for admission to inpatient care were not met. The patient did not have hypoxemia (partial pressure of oxygen < 60 mmHg or an oxygen saturation < 90%), hemodynamic instability, severe or persistent altered mental status, severe or persistent dehydration, ventilator assistance needed, bacteremia, CURB-65 score of 3 or greater, PSI class IV or V, CRB-65 score of 2 who did not improve with observation care treatment, outpatient treatment failure, appropriate diagnostic testing and treatment unavailable in outpatient or recovery facility, respiratory findings (e.g., tachypnea) that do not respond to observation care treatment, complicated pleural effusions (e.g., empyema, exudative, loculated), immunocompromised patient, or isolation that cannot be performed at an alternate setting.[4]