Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia 
Treatment: Inpatient hospital admission 
The insurer denied the inpatient hospital admission. 
The denial is overturned. 

The patient is a male with a past medical history of hypertension, diabetes, asthma, obstructive sleep apnea (OSA), who presented for cough and fever. Upon admission, the patient was noted to be hypoxemic in the 80's. Review of system was negative for additional clinical symptoms. The patient was afebrile and was described as in no acute distress. His blood pressure was 133/75, pulse rate was 111, respiratory rate was 20, and oxygen saturation was 95% on room air. The physical examination was remarkable for bilateral wheezing. 

Laboratory evaluation demonstrated a sodium of 137, potassium was 3.9, chloride was 100, carbon dioxide (CO2) was 25, blood urea nitrogen (BUN) was 11, creatinine was 1.40, glucose was 240, white blood cell count (WBC) was 11.5, hemoglobin (Hgb) was 12.0, hematocrit (Hct) was 36.3, and platelets were 370. Chest x-ray was reported as positive for pneumonia. 

The patient was admitted for sepsis due to community acquired pneumonia, asthma exacerbation and acute hypoxemic respiratory failure. The patient was treated with ceftriaxone and azithromycin, solumedrol and duonebs. The patient needed 2 liters (L) of oxygen via nasal canula. 

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

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

The requested health service/treatment of inpatient hospital admission was medically necessary for this patient. 

The patient was admitted for acute hypoxemic respiratory failure and required the use of supplemental oxygen to maintain oxygen saturation greater than (>) 94% (percent) on room air. Inpatient hospital admission was justified given the presence of wheezing, hypoxia, and asthma as a significant comorbid condition. 

Among patients with Community Acquired Pneumonia (CAP), outpatient treatment mortality ranges from 1% to 5%. Based on these mortality rates, tools for predicting the severity of College of American Pathologists have been developed and is actively used in clinical practice. The Pneumonia severity index (PSI) is an important scoring system that can assess the severity of CAP and can determine admission status. In this particular case, the patient's PSI is calculated as 93 points which represents Class 4 (IV) with an 8.2-9.3% mortality. An additional risk stratification tool called the CURB-65 can be used for triage of patients for admission. The CURB-65 for pneumonia severity in this case is 1 point which represents a low-risk group. Although the above risk stratification tools are helpful in the triage of patients, the tools do not take into account the degree of hypoxemia, need for ventilation and overall mortality due to comorbid conditions. 

Mortality rates for pneumonia in older adults are high and have not decreased in the last decade. Admission to the Intensive Care Unit (ICU) is appropriate in many patients with severe CAP who require high level of care. The Infectious Diseases Society of America/American Thoracic Society guidelines for CAP management from 2007 proposed criteria for severe CAP. Major criteria include mechanical ventilation and septic shock. There are nine minor criteria, including CURB components, as well as hypothermia, low oxygen saturation, bilateral or multilobar infiltrates, leukopenia, and thrombocytopenia. One major criteria, or 3 minor criteria indicate the need for intensive care unit (ICU)  admission. In this case, the patient fulfilled 2 minor criteria for admission to ICU (low oxygen saturation, multilobar infiltrates). 

Therefore, the requested health service/treatment of inpatient hospital admission was medically necessary.