Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
The patient presented to the hospital as recommended due to shortness of breath, chest pain, and an oxygen saturation of 91 to 92 percent (%). The patient was recently diagnosed with asthma while in the emergency department 5 days prior. The patient denied prior history despite emergency department notes. The patient reported nonproductive cough and chills. Vital signs noted blood pressure 111/69, pulse of 107, respirations of 16, and temperature of 98.3 degrees Fahrenheit. The patient's oxygen saturation was 95% on room air. Lung sounds noted scattered wheezing and decreased breath sounds. Radiographs of the chest revealed interval development of right basilar opacity medially that suggested pneumonia in the proper clinical setting. There were reticular densities in the left lung base medially suggesting atelectasis. However, developing airspace disease could not be excluded. The patient had a low potassium of 2.2 on venous blood gas and 2.6 on the basic metabolic panel (BMP). The potassium was replaced, and the patient remained low. The white blood cell count was 17.99. The patient had elevated lactate along with pneumonia on the chest x-ray. Given the patient's drop in oxygen saturation, pneumonia, and hypokalemia, it was recommended that the patient be admitted for intensive treatment and monitoring. Hypokalemia and elevated lactate were likely secondary to nebulizers and elevated white blood cell count could be secondary to steroids. Discharge diagnoses included acute asthma exacerbation in the background of community-acquired pneumonia, hypokalemia likely in the setting of hourly albuterol inhaler use, leukocytosis reactive in the setting of steroid use, hyponatremia, lactic acidosis, and respiratory alkalosis likely due to tachypnea. 

The inpatient admission was substantiated by the clinical documentation provided for review. A summary of the patient's hospital course was documented. The patient had a history of mild intermittent asthma. He was sent from a treating provider to the emergency room for further evaluation due to worsening chest tightness, shortness of breath at rest, worsening cough that was productive, and subjective fever and chills. The patient did not respond to initial Solu-Medrol and nebulizer outside of the hospital. His presenting vital signs were significant for tachycardia. He had critically low potassium level of 2.2 on venous blood gas. The lactic acid was elevated at 1.8. The patient had a potassium level of 2.6 on BMP and hyponatremia of 133. The patient had elevated white blood cell count and increased percentage of neutrophils consistent with an infection. Imaging showed interval development of right basilar opacity that suggested pneumonia in the proper clinical setting. The patient required an admit to the hospital due to evaluation and management of critically low potassium and for acute exacerbation of asthma in the setting of pneumonia. The patient met criteria to be admitted due to acute exacerbation of asthma with concomitant pneumonia, and hypokalemia. The criteria were met for inpatient treatment for hypokalemia.

Per the cited references, admission for pneumonia is indicated when there is hypoxemia, hemodynamic instability, altered mental status that is severe or persistent, when there is dehydration that is severe or persistent, when ventilatory assistance is needed, or when there is failure of outpatient treatment as indicated by insufficient improvement or worsening of signs or symptoms despite adherence to appropriate outpatient regimen of a sufficient duration or inability to tolerate outpatient regimen.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is substantiated.