Diagnosis: Pneumonia.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of hypertension (HTN) and diabetes mellitus (DM) who presented with a fever, fatigue, cough, and congestion worsening over the prior 5 days.
In the emergency department (ED), her temperature was 99 degrees Fahrenheit, blood pressure (BP) 123/61, heart rate (HR) 77, respiratory rate (RR) 20, peripheral capillary oxygen saturation (SpO2) 99% on room air (RA). She was in no distress, was breathing comfortably, with a mild wheeze, and alert and oriented. Her white blood cell count (WBC) was 4.9, sodium (Na) 141, bicarbonate 32, blood urea nitrogen (BUN)/creatinine (Cr) 7/0.72; arterial blood gas (ABG) 7.38/54/73. A computed tomography pulmonary angiogram (CTPA) found no pulmonary embolism (PE) but did uncover multifocal infiltrates. She was diagnosed with pneumonia and started on ceftriaxone and azithromycin. She was feeling better; the antibiotics were continued. She was saturating well on room air (RA), and the antibiotics were continued. She felt ready to go home, but was noted to be wheezy, and prednisone was considered. She was doing better, with no further wheezing, and she was discharged on cefpodoxime and azithromycin.
At issue is the medical necessity of an inpatient stay.

An inpatient admission was not medically necessary.
The patient presented with a fever and congested cough and was diagnosed with pneumonia. She was not severely ill at presentation, no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury or major electrolyte abnormality. She had evidence of chronic but not acute hypercarbic respiratory failure. Scoring systems would suggest a low risk of worsening. She improved over an observation care length of stay. With a low severity of illness, low risk of worsening, and no alternative diagnoses, she did not need close inpatient only testing, monitoring, or treatment, and with improvement over an observation care time frame, she did not need prolonged treatment. As such, she did not need an inpatient admission. Care could have been provided at a lower level.