This is a patient with a medical history of traumatic brain injury, kidney stones, depression and past alcohol/polysubstance abuse. He presented with symptoms of a mild headache, unsteady gait and dizziness for three to four days prior to admission. He was found to have a left lung base pneumonia but without pleural effusions/empyema or necrotizing pneumonia. The health plan's determination of medical necessity is upheld.

Based upon the severity of illness and intensity of required therapy, the inpatient level of care was not medically necessary. As per the clinical documentation, during all dates of service, the patient was hemodynamically stable, his oxygen saturation was reported greater than (>) 91% on room air and he was never in any respiratory distress or have a respiratory rate greater than or equal to (¿) 30. The chest x-ray did not demonstrate evidence of a pleural effusion/empyema/abscess/necrotizing pneumonia. He was alert, awake and oriented throughout his stay and his CURB-65 score (which estimates mortality of community-acquired pneumonia) was 0 and Pneumonia severity index (PSI) score was class 2, putting him at low risk for adverse outcomes and outpatient treatment would be appropriate. In addition, he had not failed outpatient therapy and was able to take oral medications and feeds.