Diagnosis: Pneumonia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is a pre-school male child with medical history significant for moderate persistent asthma, eczema, allergic rhinitis, and bronchiolitis. He presented to the ED (emergency
department) with two-week history significant for cough and sneezing and four-day history of fever to 103.2 Fahrenheit, post-tussive vomiting, rapid breathing, and poor intake. The patient's vital signs included temperature 37.6, heart rate 145, respiratory rate 24, and 97% oxygen saturation in room air. The patient's examination was significant for no acute distress, moist mucous membranes, tachycardia, tachypnea, decreased air movement over the posterior lower lobes, no wheezing, benign abdomen, and non-focal neurologic exam. Chest x-ray revealed airspace
opacities in the right upper lobe and bilateral lower lobes suspicious for pneumonia. Laboratory evaluation was significant for negative rapid viral screen, glucose 66, WBC (white blood count) 6.7 thousand, hematocrit 60.9 with hemoglobin 19.7, CO2 (carbon dioxide) 19, potassium 6.2. He was treated with a normal saline bolus and a dose of ceftriaxone prior to admission for further management. Admission orders included continuous cardiorespiratory monitoring, regular pediatric diet, maintenance IV (intravenous) fluids, follow-up blood culture, Miralax routine, ceftriaxone every 24 hours, budesonide twice daily, albuterol every four hours, and montelukast daily. Following admission, the patient remained hemodynamically stable with no further tachycardia. Repeat CBC (complete blood count) revealed normalization of his hematocrit to 34.6. Initially, he was only able to tolerate sips, with ongoing vomiting. By day two he had an episode of vomiting in the morning but no further episodes throughout the day. Repeat potassium had also normalized to 3.7. Blood culture remained negative. He was deemed stable for discharge on day #3 to complete seven days of amoxicillin-clavulanate and continue with budesonide, cetirizine, fluticasone,
montelukast, and albuterol.

The Inpatient Hospital Admission was medically necessary and
appropriate for this child.

This young male child with significant atopic disease including moderate persistent asthma presented with fever, cough, post-tussive emesis, poor intake, and decreased urine output.
Laboratory evaluation revealed hypoglycemia,
hemoconcentration, and metabolic acidosis. Chest x-ray revealed multifocal infiltrates. He was admitted for management of pneumonia, acute asthma exacerbation, and dehydration. He was treated with parenteral antibiotics to treat the pneumonia, intravenous (IV) fluids and anti-emetics to address vomiting and dehydration, and bronchodilators along with his preventive medications to manage his acute asthma exacerbation. The level of care required to manage multiple medical problems or complications is most consistent with acute inpatient level of
care. He could not have been safely managed at a lower level of care.