Respiratory System/Pneumonia
Inpatient Hospital/Inpatient Hospital Admission
The health plan denied the inpatient hospital admission as not medically necessary. The health plan's determination is overturned.

The patient is a male who was admitted to the hospital for pneumonitis and a heart attack. He has a history of substance abuse. On presentation, the patient was found unresponsive and cyanotic. He was given Narcan and was transferred to this facility. He abuses amphetamines, Ketamine, and Xanax. He had crackles and tachycardia with an elevated troponin. His white blood cell count (WBC) was 14.6. A urine drug screening (UDS) and positive for cocaine and amphetamines. An electrocardiogram (EKG) noted ST elevation. He was stated on Rocephin and Azithromycin in addition to Lovenox. The patient's mental status quickly improved and he was eventually discharged in stable condition.
At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination of medical necessity is overturned, in whole.

The requested service/treatment was medically necessary.
The patient in question does meet medical necessity for the acute inpatient level of care per current literature and standard of care. The patient had possible airway compromise due to overdose and developed pneumonia. The patient was at high risk of decompensation and death secondary to the overdose and developing pneumonia. Due to the acuity of presentation, an alternate level of care would not have been appropriate.