Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history of human immunodeficiency virus (HIV), diabetes, hypertension (HTN), asthma, esophagitis, tobacco use, candidiasis, polysubstance abuse, pericarditis, and cryptosporidium infection, who presented to the emergency room (ER) with chest pain and intermittent epigastric pain. He had an associated dry cough, shortness of breath, nausea/vomiting, and diarrhea.

The patient was admitted for pneumonia, as well as to work up his other medical complaints (abdominal pain, diarrhea, nausea/vomiting). He was given intravenous (IV) fluids. He was given IV ceftriaxone and azithromycin. He had a gastroenterology consult. He was placed on a proton pump inhibitor (PPI). He did not have diarrhea while admitted. His condition improved. The patient's initial vital signs were a blood pressure (BP) of 122/82, heart rate (HR) 67, respiratory rate (RR) 18, temperature 97.8 degrees Fahrenheit, and oxygen saturation 100% on room air.

Lab results were significant for a low magnesium (1.6), elevated creatine kinase (595), troponin negative, and pro-calcitonin negative.

A chest x-ray showed diffuse bilateral opacities compatible with atypical pneumonia. A repeat chest x-ray showed clear lungs. An x-ray of the right finger showed no fracture or dislocation. An abdominal ultrasound (US) showed a contracted gallbladder, no biliary ductal dilation, no right hydronephrosis or stone. An electrocardiogram (EKG) showed normal sinus rhythm. 

At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. This patient could have been safely and appropriately managed at a lower level of care, and did not require acute inpatient management.

The patient was admitted for numerous complaints, but was found to have community acquired pneumonia on the initial chest x-ray. He was started on ceftriaxone and azithromycin.

A CURB-65 [confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65] score was 0 and Pneumonia Severity Index (PSI) risk class 2. He did not have any major criteria for severe community acquired pneumonia, such as invasive mechanical ventilation or septic shock with the need for vasopressors.

Using his PSI risk class of 2, he would be considered low risk: "Among low-risk patients (Pneumonia Severity Index class less than 3 or CURB-65 score less than 2), the likelihood ratio (LR) for 30-day mortality using the index is 0.08, and 0.21 using CURB-65. Sensitivity for predicting intensive care unit (ICU) admission was reported as 74% versus 39% to 50% for Pneumonia Severity Index versus CURB-65, respectively."

Furthermore: "Although CURB-65 has a higher false-negative rate (i.e., incorrectly ruling out severe community acquired pneumonia [CAP]) compared with other instruments, its relatively high specificity allows physicians to more accurately advance treatment for patients with a score of 3 or greater while taking further measures to determine risk in patients who score low. CRB-65 [confusion, respiratory rate, blood pressure, age greater than or equal to 65] is more practical for use in the primary care setting without a significant compromise in prognostic value. Patients with a score of 0 or 1 can be managed safely as outpatients." This patient had a CURB-65 score of 0, and could have been safely managed as an outpatient.

An inpatient stay was not medically necessary.