Diagnosis: Legionella Pneumonia
Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.
The denial is overturned.

The patient presented to the emergency department (ED) with 1 week history of fever and diarrhea. The patient had a temperature max to 103. He was seen at an urgent care center where he was prescribed Amoxicillin for possible ear infection. In the ED, vital signs were 102.2, Blood Pressure 119/71, Heart Rate 104, Respiratory Rate 18, and Oxygen (O2) saturations 98% (percent). The patient was noted to have Rales on right base on exam.
White blood cell count (WBC) was 11.4 with bands of 14% hemoglobin 12.5, sodium 129 BUN (blood urea nitrogen)/Creatinine (Cr) 26/2.08 liver function tests (LFT) were also elevated urinalysis (UA) was positive for lower extremity (LE) and 5-10 WBC. Chest x-rays (CXR) revealed right lower lobe (RLL) infiltrate consistent with Pneumonia. The patient initially received antibiotics - Cefepime/Vancomycin for treatment of Sepsis. A computed tomography (CT) scan of the chest was done which revealed that the patient had a lobular consolidation of right lower lobe (RLL) consistent with Pneumonia.

This patient was admitted to the Hospital for treatment of pneumonia, acute kidney disease (AKI), and hyponatremia. The patient was continued on intravenous (IV) hydration for his AKI. Antibiotics were switched to Rocephin and Azithromycin. The patient was still febrile 99-101.5 Fahrenheit (F), BUN/Cr 23/1.9. The patient was still hyponatremic. Liver function tests (LFT) were abnormal and the patient continued on hydration and antibiotics.

Later, temperature range 99- 101.3 F blood urea nitrogen/ creatinine (BUN/Cr) 16/1.6 Sodium 136. The patient Labs came back positive for Legionella Pneumonia. The patient was then switched to Azithromycin. Rocephin was discontinued. The patient went home on oral (PO) Azithromycin to complete course of 10 days.

This patient had Legionella Pneumonia with evidence of MOSF (multi organ system failure) - the patient had AKI, Abnormal LFT's, Hyponatremia and hypokalemia. The patient needed admission for close monitoring of all his labs, hydration and appropriate management of his renal failure and electrolyte abnormalities. Based on these multiple issues inpatient admission was appropriate.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.