Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART), medical noncompliance with her HIV medications, bronchial asthma, chronic obstructive pulmonary disease (COPD), and tobacco abuse who presented to the emergency department with complaints of chest pain and shortness of breath.
She complained of retrosternal chest pain that did not radiate. The patient described the pain as stabbing, 10/10 in severity and aggravated by movement and taking a breath. It was partially alleviated by taking Tylenol. The patient had this pain for approximately 1 week. It was continuous. Because of the pain, the patient was unable to lie flat and required 2 extra pillows. She also complained of a cough with greenish sputum and streaks of blood. In addition, the patient noticed a high fever and shortness of breath.
On the initial evaluation, the patient was afebrile. Her temperature was reported as 98.3 degrees Fahrenheit (F), respiratory rate 18, blood pressure 122/86, and oxygen saturation 96%.
On the physical exam, it was noticed that the patient used accessory muscles for breathing. She had rhonchi and crepitations in the lower two-thirds of the right lung with no wheezes. The cardiac exam was unremarkable.
A chest x-ray demonstrated chronic interstitial lung disease with increased right basilar opacity concerning for pneumonia.
A computed tomography (CT) scan of the chest demonstrated right middle lobe pneumonia or pulmonary pneumonitis. The patient had advanced emphysema and mild chronic interstitial lung disease.
The patient was admitted to the hospital with a diagnosis of pneumonia as well as COPD with acute exacerbation, anemia, chronic kidney disease, depression, HIV disease, weight loss.
She was started on intravenous antibiotics, intravenous fluids. Blood cultures were obtained and infectious disease consult was requested. In addition, the patient received a dose of Solu-Medrol because of acute exacerbation of the chronic obstructive pulmonary disease. The patient's HIV medications were continued.
Reportedly, the patient left the hospital against medical advice on the day of admission. The health plan's determination is upheld.
According to the accepted standards of care for patients with HIV, empiric treatment with antibiotics is dependent upon the clinical presentation. In patients presenting with typical symptoms of bacterial pneumonia plus focal consolidation on chest radiograph, the initial antibiotic regimen will be directed at the most common community-acquired pathogens.
The decision to treat as an outpatient or inpatient will depend on the clinical status and the reliability of the individual. The approach to the treatment of community-acquired pneumonia is similar to that in the HIV-seronegative patient.
HIV-infected patients who present with suspected bacterial infection with single lobar involvement and good respiratory status may be considered for outpatient therapy.
Like in this clinical case, the patient definitely had community-acquired pneumonia but was afebrile, hemodynamically stable, had normal respiratory rate, and normal oxygen saturation.
CURB-65 Score [confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65] for Pneumonia Severity was applied in this case. This is a risk stratification tool that helps to estimate the mortality of community-acquired pneumonia to help determine inpatient versus. outpatient treatment. Based on the calculations, the patient did not require admission at the acute inpatient level of care. Considering the severity of the pleuritic chest pain due to pneumonia and also concomitant COPD exacerbation, a lower level of care was reasonable to assess clinical response as well as adherence to medications, adequate pain control, and adherence to the treatment regimen.