Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

This female patient, with no significant past medical history, was admitted to acute in hospital level of care with the diagnosis of pneumonia. The patient had a previous infection with COVID-19 but had recovered from it. The patient was treated with antibiotics as an outpatient without any improvement.

Yes, the proposed Inpatient Hospital Admission was medically necessary.
This patient had pneumonia and had tried and failed outpatient treatment. During the hospitalization, the patient had episodes of high fevers and hypotension due to pneumonia. The patient had multi focal pneumonia that was not clinically improving and the antibiotics were changed to intravenous linezolid. Due to multifocal pneumonia, the patient had persistent chest pain and required pain medications. The patient also required consultations by Cardiology, Pulmonary and Infectious Disease. The patient had prolonged hospitalization for difficult to treat pneumonia and it's associated symptoms. The acute in hospital level of care in this case is standard of medical practice. The entire admission was medically necessary.

This patient was admitted to acute hospital level of care. The patient had multifocal infiltrates and had tried and failed outpatient medical management. The patient had evidence of sepsis, likely due to pneumonia, at the time of admission. The patient was started on intravenous antibiotics as well as intravenous fluids. During the hospitalization, the patient had episodes of fevers and pleuritic chest pain that was not improving. The patient was seen by Pulmonary, Cardiology as well as Infectious Disease specialists. Due to persistent fevers, the patient underwent bronchoscopy. The patient was being ruled out for fungal infection as well as hypersensitivity pneumonitis. Since the patient continued to have fevers, the antibiotics were changed.

As the patient had multifocal pneumonia and had failed outpatient treatment, the acute in hospital level of care is medically necessary. Despite appropriate intravenous antibiotics, the patient continued to have fevers and tachycardia as well as chest pain. This required prolonged hospitalization. The entire admission was medically necessary.