Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community acquired pneumonia. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

 
The patient presented to the hospital due to shortness of breath associated with chest tightness x1 day. She denied a history of asthma. However, over the past year, the patient had noted episodes of shortness of breath after exercising and smoking that resolved upon resting. She endorsed a cough with clear sputum production. Vital signs of the patient noted a temperature of 98.3 degrees Fahrenheit, blood pressure 114/72, heart rate of 100, respirations of 22, and an oxygen saturation of 97 percent (%) on room air. Laboratory testing was significant for leukocytosis and elevated inflammatory markers. A pulmonary embolism could not be ruled out given borderline tachycardia and a recent surgical procedure. An electrocardiogram (EKG) was ordered for sinus tachycardia. The D-dimer was elevated to 0.8 and troponin was negative. The interpretation of the EKG was ischemic changes. The patient was found to have pulmonary edema on radiographs. A computed tomographic angiogram (CTA) showed no evidence of a pulmonary embolism. However, there was ground-glass opacities with peripheral scarring and upper lobe predominance. The findings could represent atypical pneumonia versus noncardiogenic edema but was not typical of COVID pneumonia. Influenza and rapid COVID were negative. The patient was admitted to cardiac telemetry for continuous monitoring and work-up consisting of a stress test, serial troponins, and potential heart catheterization. 

The patient was treated with duo nebulizers which resulted in improvement in symptoms. She was started on antibiotics and had a resolution of symptoms. Infectious disease and pulmonology were consulted due to image findings. Infectious disease recommended a completion of work-up. The patient was stable and did not want to remain in the hospital despite recommendations for completing a full work-up. She was discharged on 5 days of Levaquin. The primary diagnosis was shortness of breath secondary to community-acquired pneumonia versus viral pneumonia, rule out acute coronary syndrome. The patient had a secondary diagnosis of asthma with exacerbation. 

Per the cited references, admission for pneumonia is indicated when there is hypoxemia, hemodynamic instability, altered mental status that is severe or persistent, when there is dehydration that is severe or persistent, when ventilatory assistance is needed, or when there is failure of outpatient treatment as indicated by insufficient improvement or worsening of signs or symptoms despite adherence to appropriate outpatient regimen of a sufficient duration or inability to tolerate an outpatient regimen. An admission for chest pain may be indicated when there is hemodynamic instability such as with tachycardia that persist despite appropriate treatment, hypotension that persist despite appropriate treatment, or orthostatic hypotension. An admission for chest pain may be indicated for patients with dyspnea, tachypnea, an abnormal breathing pattern, or further evidence of difficulty breathing. However, observation level of care may be appropriate when there is suspected myocardial ischemia in patients classified as intermediate risk and when pain persists despite emergency department care. Observation level of care is also warranted when the suspected diagnosis requires observation and monitoring during diagnostic evaluation such as pulmonary embolus, aortic dissection, pneumothorax, pericarditis, and gastrointestinal bleeding. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.