Diagnosis: Respiratory system /pneumonia
Treatment: Inpatient hospital
The insurer denied the acute inpatient hospital stay.
The denial is Overturned in whole.


The patient in this case who presented to the emergency department (ED) with complaints of productive cough with yellow sputum as well as fevers with hot flashes and chills that was ongoing for 3 days prior to admission. The patient lives in a shelter and has a history of asthma and blindness due to an injury as a child. The patient has lived in a shelter for the last 2 years and had no sick contacts. The patient presented with tachycardia (heart rate (HR) 110) and respiratory rate was 18.
The patient lives in shelters and this is a significant risk factor for development of TB infection. Due to this risk, he required hospitalization for infection control in a manner that is not able to be monitored in lower level of care.
This patient, as documented, lives in a shelter. Shelters are a risk factor for acquisition of pulmonary tuberculosis. This is related to the inherent heterogeneity of individuals who will reside in the area at any given point in time. Tuberculosis, as a disease, is spread via respiratory droplets and, when you live in a shelter, the common areas where people stay tend to be poorly ventilated (in comparison to a negative pressure room) such that droplets become aerosolized and are able to be inhaled by those who are living there. The individuals who go to the shelters will have no idea of the health status of anyone else so it would be impossible to know if they were infected without performing the standardized screening, which is a sputum culture for acid-fast bacteria (AFBs). This requires the patient to produce a sputum sample that must be analyzed by the lab to determine if there is evidence of the bacteria. This sputum sample is taken over 3 days so that a representative sample can be obtained for screening. Based on standard of care, this would require an inpatient level of care as TB is a public health disease with significant ability to cause morbidity if left to run rampant. It is because of this that the patient required an inpatient level of care.