Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male with autism who presented with fever and worsening cough. He was well until 6 days prior to presentation when his school called to report that he was coughing. He then developed a fever to 103 Fahrenheit (F). He was evaluated at that time and was given ibuprofen. However, his cough continued, so he was brought back to urgent care where he received prednisone and a nebulizer treatment. His fevers continued and he was eating and drinking less than usual, and his lips had become dry and cracked. He was also complaining of neck and knee pain. He was therefore brought to the emergency department for care.

In the emergency department he was found to be irritable with a temperature of 101.1 F. On examination he had dry mucous membranes and cracked lips and had right-sided facial tenderness. His lung exam revealed coarse crackles with dullness on the right lung. He was given 3 albuterol/Atrovent nebulized treatments as well as dexamethasone. A chest x-ray was obtained which revealed a lingular pneumonia with prominent interstitial markings. Laboratory values revealed a white blood count of 20.2 with 88% neutrophils, and a C-reactive protein (CRP) of 15.3, His oxygen saturation dropped to 90% on room air, so he was placed on 2 liters (L) oxygen by nasal cannula. He was subsequently admitted to the hospital for further care.
In the hospital he was continued on 2 L oxygen, intravenous fluids, and albuterol treatments every 4 hours. He was also given intravenous Unasyn and oral azithromycin. He improved over time, became stable on room air, and his oral intake improved. He was felt to be stable for discharge to home with follow-up as an outpatient.
The subject under review is the medical necessity for the inpatient stay.

The inpatient stay medically necessary for this patient. This is a patient with moderate persistent asthma who presented with fever, decreased oral intake, and cough, who was found to have pneumonia and elevated inflammatory markers. He required multiple breathing treatments in the emergency department and became hypoxemic with an oxygen saturation of 90%. He therefore required inpatient admission for continued breathing treatments as needed, supplemental oxygen, parenteral antibiotics, and intravenous fluids.
Children with pneumonia require hospitalization if they have hypoxemia, and if they are unable to meet their hydration needs orally. This patient had hypoxemia and required supplemental oxygen. He also had decreased oral intake and dry lips. Since patients with pneumonia and fever have increased insensible fluid loss and therefore greater fluid needs, he required intravenous fluids to maintain his hydration status. He also had fever with elevated inflammatory markers and required initial treatment with parenteral antibiotics.
The decision making at the time of admission for this patient was consistent with his age, the presence of pneumonia with fever, hypoxemia, and decreased oral intake, and the need for parenteral therapies, supplemental oxygen, and close monitoring for potential deterioration of clinical status.