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202006-129075

2020

HIP Health Plan of New York

HMO

Respiratory System

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Respiratory System
Inpatient Hospital

Diagnosis: Pneumonia
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a girl who presented with fever and vomiting. She was well until 6 days prior to admission when she developed nausea and vomiting. She also had a nonproductive cough. She continued to have daily fevers for the next 6 days and was subsequently brought to the outpatient clinic. She was referred from the clinic to the emergency department due to concern for pneumonia.

The inpatient hospital admission was medically necessary for this patient.
This is a young girl who presented with cough, nausea, and vomiting. She was febrile for 6 days at the time of presentation. She was initially seen in her primary care office but was referred to the emergency department due to concerns of pneumonia. Upon presentation, she was found to have fever, an oxygen saturation of 95%, and crackles on her right lower lung base consistent with clinical pneumonia. She was also found to have an elevated white blood count with a left shift indicated systemic illness. During her time in the emergency department, she became more fatigued and drowsy, and required a bolus of intravenous fluids as well as parenteral ceftriaxone. She was admitted for ongoing treatment of pneumonia with intravenous antibiotics as well as intravenous fluids to maintain her hydration status. Due to her prolonged fever and ill appearance, she required prompt treatment with careful monitoring.

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