Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia 

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a male who presented to the Emergency Department complaining of abdominal pain as well as nausea/vomiting and general malaise since the prior day.  He did have a history of pancreatitis and stated he felt similar to prior episodes.  The physician indicated the patient stated he had elevated glucose earlier in the day and no reported fever.  Physical examination revealed no costovertebral tenderness to percussion. There were bowel sounds with diffuse epigastric tenderness to palpation without guarding or rebound.  The recommendation was made for the patient to undergo laboratory and diagnostic studies.  The patient underwent computed tomography scan that did not reveal any acute findings however the patient did have a bandemia of 9% with neutrophil predominance and elevated lactate.  The physicians indicated there was concern for bacteremia/sepsis of unclear etiology.  The patient did undergo a chest x-ray showing pneumonia.  The documentation indicated the patient was stabilized in the emergency department and it was recommended that he be admitted for further treatment.  The patient was treated with intravenous antibiotics.  He continued with treatment and additional monitoring.  Throughout the remainder of the stay, there were no significant adverse events.  The patient continued to improve and was discharged with oral antibiotics. 

This patient had no significant laboratory abnormality, no peritoneal signs or acute abdomen, no end organ damage or abnormality that warranted inpatient status.  The patient could receive intravenous fluids, antibiotics, and intravenous pain medication in observation status and not have his health jeopardized.  There was concern for sepsis with elevated lactate and bandemia but these could be followed and observed in ambulatory or outpatient setting rather than acute inpatient admission status receiving the same level and quality of care.  In the setting of severe sepsis not responding to emergency setting care this admission would have been appropriate.  Patients that need hospitalization are those with the following signs and symptoms:  Volume depletion/dehydration, altered mental status, significant rectal bleeding, prolong symptoms (more than a week), severe abdominal pain, comorbidities such as immune compromise and diabetes (immunocompromised status),  recent hospitalization or antibiotics, pregnancy, or weight loss.  There was no fever or severe abdominal pain requiring hospital admission rather than ambulatory setting such as observation.  Lab data showed mild acid/base derangement, no electrolyte discrepancy, or renal impairment that needed acute hospital inpatient admission status.  Hydration, intravenous pain medications, and monitoring in ambulatory setting were appropriate for this patient and would not have jeopardized his well-being 

The health plan acted reasonably with sound medical judgement in the best interest of the patient.

The insurer's denial of coverage for inpatient hospital admission is upheld.  Medical necessity is not substantiated.