Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath; dry cough. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This homeless male with a history of polysubstance abuse presented for detox from heroin and cocaine.  He admitted to dry cough and shortness of breath (SOB). The patient's vital signs (VS) revealed the following: temperature 98.2, pulse 63, respiratory rate (16), blood pressure 160/85, and oxygenation (97%).  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was four. The patient's exam was unremarkable.  His labs revealed the following: white blood cell (WBC) count 8.4, hemoglobin/hematocrit (H/H) 15/43.6, platelets 291, sodium (Na) 142, potassium (K) 4.3, blood urea nitrogen (BUN) / creatinine (Cr) 13.9/1.07, and brain natriuretic peptide (BNP) 786.  Urine toxicology was positive (+) for cocaine and opioids.  Chest x-ray (CXR) showed left lower lobe (LLL) consolidation and pleural effusion.  Electrocardiogram (EKG) showed sinus tachycardia - sinus bradycardia.  

The patient was admitted.  The plan of care included intravenous (IV) antibiotics and fluid restriction.  The following day, echocardiogram showed left ventricular (LV) dilation and hypertrophy and apex hyperkinesis; ejection fraction (EF) was 35-40%.  Day 3, vital signs were stable. The patient had shortness of breath (SOB) due to congestive hear failure (CHF) versus pneumonia.  The patient left against medical advice (AMA).  

No, the proposed inpatient admission was not medically necessary.  

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, the least intensive and/or most appropriate alternatives among diagnostic and treatment option. 

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice. 

This patient with a history of polysubstance abuse was admitted.  He presented for detox and was found to have pulmonary consolidation and effusion.  He was hemodynamically stable and afebrile.  He did not have leukocytosis.  He did not have electrolyte abnormalities or renal failure. He did not have signs of withdrawal.  Treatment included intravenous (IV) antibiotics for pneumonia.  He had not failed a lesser level of care. 

CURB-65 (confusion, urea, respiratory, blood pressure) uses five prognostic variables in providing a risk assessment for patients with community acquired pneumonia (CAP):
Confusion; Urea greater than (>) 7 millimoles per liter (mmol/L) (20 milligrams per deciliter [mg/dL]); Respiratory rate 30 breaths per minute; Blood pressure (BP) (systolic less than [<] 90 millimeters of mercury [mmHg] or diastolic 60 millimeters of mercury [mmHg]; and Age 65 years.  

A CURB-65 score of zero to one indicates low risk and can be treated as outpatients; a score of two should be admitted to the hospital; and those with a score of three or more should be assessed for care in the intensive care unit.  

This patient was at low risk based on his CURB-65 score of one due to blood urea nitrogen (BUN) greater than (>) seven.  Based on these findings, inpatient hospital admission was not in accordance with generally accepted national standard of medical practice and medically necessary.