CLINICAL SUMMARY: Bilateral Pneumonia
A 23-year-old nonverbal female patient arrived in the emergency department with her parents who said she had a fever and heavy breathing since the morning. The patient’s medical history included Lennox-Gastaut Syndrome, severe mental retardation, seizure disorder, recurrent aspirations, recurrent pneumonia and vagal nerve stimulator. Her parents said she had been suffering with flu-like symptoms for the previous week. However, she had no cough, vomiting or abdominal pain. It is noted that the patient was not physically able to cough. She had been vaccinated for COVID-19 and received a booster as well as the influenza vaccine.
Her vital signs were as follows: VS: T max 102.8, pulse 106-141, respiratory rate 20-41, blood pressure 87/41-107/52, Oxygen saturation 95% room air. Bilateral crackles on lung exam. Labs: WBC 12.87, Hgb 13.0, platelets 366, Na 139, K 3.6, BUN 12, Cr 0.64, glucose 102, lactate 1.9, CRP 61.8, BC x2: NG, Respiratory Filmarray: COVID-19: negative, Parainfluenza Virus 4: + IMAGING: CXR: Bilateral interstitial opacities are suspicious for infection.
IV fluids and Tylenol were administered in the ED with no significant improvement in her status, so the patient was admitted and started on IV antibiotics for sepsis due to bilateral pneumonia. She had a PSI score of 43, Class II (criteria met: 23 y/o, Female, respiratory rate >30, Heart rate >125).
By the next day in the hospital, the patient’s fevers resolved, and her lungs were clear to auscultation bilaterally upon examination. The family said the patient was at her baseline. They asked for the patient to be sent home if possible. After consultation from infectious disease, the patient was cleared for discharge on oral antibiotics.
DENIED INPATIENT STAY
The short hospital stay was denied by the insurance company because, according to the insurance company, the stay did not meet the guidelines required for an inpatient stay. The denial notes stated that the reason for the admission was pneumonia but the patient “did not have to be admitted as an inpatient in the hospital for this care.” The insurance company also stated that the patient did not have severe illness, was stable and “had test that did not show any problems that needed inpatient only treatment.” The insurance company argued that the patient could have received the care needed without being admitted as inpatient to the hospital as the patient did not need oxygen or pain medicine through an IV.
Despite a very quick improvement and discharge the following day, the hospital felt that an inpatient stay was warranted based on the patient’s complex history and condition at presentation. A peer-to-peer discussion was requested with the insurance company. Discussing the complexity of this patient’s presentation helped overturn the denial. The P2P was completed between an AppriseMD physician and the insurance company medical director. After a discussion, the insurance medical director agreed with inpatient level of care for this high-risk patient admitted with bilateral pneumonia with evidence of sepsis. Although the patient improved and was discharged the next day, inpatient level of care was supported, and the inpatient denial was overturned.
OUTCOME: DENIAL OVERTURNED