Pneumonia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient hospitalization services. Rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, and the level of medical and nursing support. Long-term acute care hospitals (LTACH) offer physical and occupational therapy, 24-hour skilled nursing care and a clinician available 24 hours per day. The medical providers are able to care for active/ongoing medical conditions requiring a clinician-level care. In this case, the patient had pneumonia that caused her to require increased ventilator support and work-up for a fever starting 4/13/18.

A 42-year-old female enrollee has requested reimbursement for air ambulance services for treatment of her pneumonia. Findings: The physician reviewer found that a progressive multilobar pneumonia with a failure to establish a diagnosis and/or prognosis constitutes a medical emergency. A diagnosed bacterial pneumonia in a community-acquired setting has approximately a 5% mortality rate. For hospitalized patient, the mortality is increased to 15%. The general expectation is that an otherwise healthy individual should improve within one to three days of treatment. That did not occur in this instance, nor was a reasonable diagnosis established. In fact, the treating physician stated a need for air transport due to his concerns regarding the infectious and potentially contagious nature of the patient’s condition.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is a 60-year-old female with a history of chronic obstructive pulmonary disease (COPD), lung cancer, chronic kidney disease, and chronic liver failure who presented to the hospital for upper gastrointestinal bleeding, sepsis with hypoxemic respiratory failure from pneumonia and possible congestive heart failure with severe lactic acidosis. The patient was initially hospitalized in the intensive care unit (ICU) and was intubated and sedated. She was treated with intravenous (IV) antibiotics and was also noted to have worsening renal failure initially requiring continuous renal replacement therapy (CRRT) then hemodialysis (HD). She was also treated for clostridium difficile infection.

A 46-year-old male has requested coverage for emergency services. Findings: The physician reviewer found that the patient presented to the emergency department for evaluation of a dry cough for two weeks that was not improving. A medical screening exam was performed which revealed that he was afebrile with a normal respiratory rate, heart rate, and pulse oximetry on room air. Testing was performed to include an EKG, lab tests and a chest x-ray, but the patient left the emergency department prior to being seen by the physician on duty. Subsequently, he went to an Extended Hours Clinic and was seen by a physician assistant. Again, the patient was noted to be afebrile with a normal pulse, respiratory rate and pulse oximetry. Pain was not a presenting complaint, and no pain level was documented.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving pneumonia, then check the rights and deadlines that apply to your plan.