Diagnosis: pneumonia
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male with a medical history of asthma was admitted for an asthma exacerbation secondary to pneumonia with symptoms of cough with sputum production, fever and mild headache for three days prior to admission. His chest x-ray demonstrated pneumonia in the right lower lobe but did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia.

Inpatient hospital stay was not medically necessary for this patient.
This patient with a medical history of asthma was admitted for an asthma exacerbation secondary to pneumonia with symptoms of cough with sputum production, fever and mild headache for three days prior to admission. As per the clinical documentation, on admission, the patient was afebrile, hemodynamically stable, with a respiratory rate of 20 breaths per minute, oxygen saturation 93% on room air, had a normal pulmonary effort but had bilateral wheezing on auscultation of the chest. His chest x-ray demonstrated a pneumonia in the right lower lobe, but did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia. He was treated with antibiotics (Ceftriaxone & Doxycycline), Solumedrol and albuterol/ipratropium nebulizers.

He was alert, awake and oriented throughout his stay, he did not have documented hypercapnia or documented hypoxemia, he did not require any ventilatory support, he did not have a documented immunosuppressed state, bacteremia, and he was able to take oral medications and feeds. The CURB-65 score was 1 and Pneumonia Severity Index score was a risk class 2. A lower level of care would be considered reasonable. In addition, although he had acute renal injury, it was secondary to dehydration which improved with intravenous fluid hydration and his asthma symptoms improved with observation. Therefore, the Inpatient hospital stay was not medically necessary.