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

This is a male child with a medical history significant for croup and a family history of asthma who presented to the emergency department (ED) with audible wheezing and rib pain. The review of systems included right upper quadrant abdominal pain for four days associated with fevers, no bowel movement for three days, poor oral intake, vomiting, and a non-productive cough for four days. Examination was significant for no acute distress, right lower lung rhonchi and rales, left-sided chest wall tenderness, and a benign abdomen. A chest x-ray revealed a right basilar infiltrate concerning for pneumonia, and kidney ureter bladder (KUB) revealed a non-obstructive bowel gas pattern with moderate stool burden within the descending colon. He was treated with acetaminophen, ibuprofen, one DuoNeb treatment, a normal saline bolus, and ceftriaxone 1 gram (gm). He was admitted for further management of right lower lobe pneumonia.
Admission orders included continued ceftriaxone every 12 hours, follow-up pending blood culture, anti-pyretics as needed, intravenous (IV) fluids at maintenance, pediatric diet for age, continuous pulse oximetry, and vital signs every four hours. He improved the next day with no tachypnea or retractions. His appetite improved and his intravenous (IV) fluids were decreased accordingly. He remained on parenteral antibiotics and half-maintenance IV fluids. He was eating, he passed stool with resolution of abdominal pain, and he was afebrile. He was deemed stable for discharge home. At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary.
This young male child presented with poor oral intake, persistent cough with some chest pain, and audible wheezing at home. A chest x-ray revealed right-sided pneumonia. He was admitted for parenteral antibiotics and intravenous (IV) fluids. He did well and was discharged home upon resolution of difficulty breathing and belly pain. While it was not unreasonable to monitor this child in the hospital, providing IV antibiotics and IV hydration, he was overall hemodynamically stable with no evidence of impending respiratory failure, no significant metabolic abnormalities, and no serious underlying conditions. He did not require acute inpatient admission and could have been safely managed at lower level of care.