Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is overturned. 

This patient is a male admitted for a diagnosis of left lower lobe pneumonia, fever and demand ischemia of myocardium. The patient presented with a chief complaint of cough and fever. Symptoms had been present for two days prior to admission. In the emergency department, his fever was noted to be as high as 102.4F(Fahrenheit). The troponin level went from 0.03 up to 0.20. His vital signs demonstrated a temperature of 98.9F up to 102.4F. Pulse was 95, respiratory rate was 19, blood pressure was 124/79 and oxygen (O2) saturation was 100%. The physical exam showed no acute distress or altered mental status.
His white blood cell count was 6.2 with a hemoglobin at 14.2 and creatinine was 0.75. His blood urea nitrogen (BUN) was 10. Chest x-ray showed clear lungs. A computed tomography angiography (CTA) of the chest did not demonstrate pulmonary embolism but there was left lower lobe pneumonia which was favored to be bacterial etiology. The patient was treated with ceftriaxone and azithromycin. Coronavirus (COVID) testing was negative. Cardiology evaluated the patient who felt that the troponin elevation was secondary to demand ischemia in the setting of infection. The patient was transitioned to cefdinir for three more days as he was treated for five days in the hospital because it took three days for the fever to defervesce. The patient was then discharged.
At issue is the medical necessity of Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
According to UpToDate, 2021, "Clinical response to therapy - With appropriate antibiotic therapy, some improvement in the patient's clinical course is usually seen within 48 to 72 hours (table 8). Patients who do not demonstrate some clinical improvement within 72 hours are considered nonresponders.
The time course of the clinical response to therapy is illustrated by the following observations: In a prospective multicenter cohort study of 686 adults hospitalized with community acquired pneumonia (CAP), the median time to becoming afebrile was two days when fever was defined as 38.3oC (101oF) and three days when defined as either 37.8oC (100oF) or 37.2oC(Celsius) (99oF) [71]. However, fever in patients with lobar pneumonia may take three days or longer to improve. In a second prospective multicenter trial of 1424 patients hospitalized with CAP, the median time to stability (defined as resolution of fever, heart rate less than [<] 100 beats/minute, respiratory rate less than (< )24 breaths/minute, systolic blood pressure of greater than or equal to (>=) 90 millimeters of mercury (mmHg), and oxygen saturation >= 90 percent for patients not receiving prior home oxygen) was four days."
The patient in this case had a lobar pneumonia confirmed on computed tomography (CT) of the chest and had a persistent fever as high as 103.5F. The fever persisted for three days. His pneumonia severity index calculation is a risk class II which sometimes can be reasonably managed on an outpatient basis. However, in the setting of a persistent fever for three days it would not be reasonable or appropriate to discharge him with an active fever in the setting of a confirmed infection. Medical necessity of admission has been established.
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary.