Diagnosis: Respiratory System/Pneumonia.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient hospital stay as not medically necessary.
The health plan's determination is upheld.

The patient is a male with a possible psychiatric disorder, human immunodeficiency virus (HIV), and substance abuse who presented with a headache, malaise, and dry cough.
In the emergency department (ED), his temperature was 98.2F (Fahrenheit), with a blood pressure (BP) of 97/70 millimeters of mercury (mmHg), a respiratory rate (RR) of 17/minute, and an oxygen saturation of 96% (percent) room air (RA). He was in no distress, breathing comfortably with clear lungs, and he was alert and oriented. Lab results included a white blood cell count (WBC) of 5.8, a sodium of 135, a bicarb of 27, a blood urea nitrogen (BUN)/creatinine of 18/0.95, and a creatine kinase (CK) of 503. A chest x-ray (CXR) demonstrated subtle lower lobe opacities. A computed tomography (CT) of the thorax found hazy ground-glass in lingula and the left lower lobe (LLL) and scattered peripheral tree-in-bud changes.
The patient was diagnosed with pneumonia and was started on Ceftriaxone, rhabdomyolysis, for which he was started on intravenous (IV) fluids, and substance abuse, for which he was started on as needed (PRN) Lorazepam, and a possible psychiatric disorder.
The next day, the patient was seen by infectious disease (ID) who recommended checking his CD4 count (T-cell test) and sputum culture, and continuing antibiotics. He still had a cough but was improving; antibiotics were continued.
The following day, the patient was saturating well on room air. He left against medical advice after psychiatry saw the patient and felt he had the capacity to make this decision.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld.

No. An inpatient admission was not medically necessary. The patient presented with dry cough and headache and was diagnosed with pneumonia and rhabdomyolysis. His pneumonia was not severe; he was not severely ill at presentation with no organ dysfunction (encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury or marked electrolyte abnormality). By scoring systems, he was unlikely to worsen or need Intensive Care Unit (ICU) care. He improved within an observation care time frame. The main additional diagnosis was rhabdomyolysis which was quite mild (creatine kinase (CK) around 500) making the risk of complications such as acute kidney injury (AKI) extremely low. Given all of these features (low severity at presentation, low risk of worsening, low risk of complications from rhabdomyolysis, rapid improvement), an observation admission would have been reasonable; an inpatient admission was not medically necessary.