Diagnosis: Pneumonia
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial was upheld.

This is a male patient with a history of hypertension (HTN), end stage renal disease (ESRD) on hemodialysis (HD). The patient is status post renal transplant which failed (patient was back on HD). The patient presented to the emergency department (ED) on with complaints of shortness of breath (SOB), weakness, hemoptysis, and neck and chest pain. It was reported that patient had been non-compliant with his blood pressure (BP) meds. At presentation to the ED his vital signs were: temperature 99.1 F, heart rate (HR) 105, respiratory rate (RR) 18, blood pressure (BP) 199/129 mm Hg, oxygen saturation 96% on room air. The patient was in no acute distress (NAD). The lung exam revealed wheezing and rhonchi. Cardiovascular system was normal. The patient's abdomen was soft and non-tender. An electrocardiogram (EKG) was performed that revealed some non-specific T wave changes. Chest x-ray revealed bilateral perihilar haziness. The diagnosis included pneumonia vs fluid. There was no pleural effusion; there was no pneumothorax. The patient was treated with a nitroglycerine (NTG) patch, Clonidine, Rocephin and Azithromycin. The patient's symptoms improved and he was discharged.

As per the history and physical (H&P) the patient was in no acute distress, was awake and alert, had no jugular venous distension, some wheezing and rhonchi on lung exam, and the neuro exam was non focal. Influenza screen was negative.

This patient was continued on oral blood pressure meds and other maintenance meds. He was continued on antibiotics on pneumonia. The patient remained stable after admission, was afebrile, and hemodynamically stable. Troponins remained flat and EKG no changes from the first one at presentation. Cultures were negative. The patient denied on going chest pain. The patient was afebrile, HR 88, RR 17, BP 167/95 mm Hg, oxygen saturations were 100% on 2 liter nasal cannula. Myocardial infarction was ruled out.

This patient did not need acute inpatient hospitalization. He could have been placed on observation status while diagnostic testing and treatment were initiated. The patient's BP was elevated due to non-compliance with meds; he responded to treatment in ED; wbc was normal. The CURB 65 score was 1 (the patient had chronic kidney disease (CKD). By the second inpatient day the patient was on maintenance dialysis; tolerating oral intake; without chest pain; myocardial infarction was ruled out and BP was at baseline. The patient was stable to be switched to oral antibiotics and could have been discharged home with close follow-up in the outpatient setting.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.