Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD) exacerbation/bronchitis. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient with history of asthma/chronic obstructive pulmonary disease (COPD) who presented to the Emergency Department (ED) with a complaint of progressive shortness of breath (SOB) accompanied by some cough with productive greenish sputum. The patient's past medical history included hypertension (HTN) and polysubstance abuse. The patient's vital signs at ED presentation were: temperature 98.8, heart rate 109, respiratory rate 19, heart rate 114, and oxygen saturation 96%. The patient's peak expiratory flow (PEF) was 200; the patient's best PEF baseline was not known. The patient was noted to have bilateral wheezes with some decreased breath sounds; accessory muscle use was noted. The patient was diagnosed with COPD exacerbation. The patient's treatment was initiated with intravenous (IV) steroids, bronchodilator, and magnesium. In addition, the patient was started on antibiotics. The patient's labs revealed white blood cell (WBC) 12.7, hemoglobin 15.2, and his electrolytes were within normal limits (WNL). The patient's chest X-ray showed no acute infiltrates. The patient's arterial blood gas (ABG) in room air (RA) were potential of hydrogen (pH) of 7.42, partial pressure of carbon dioxide (PaCO2) 32, partial pressure of oxygen (PaO2) 73, bicarbonate (HCO3) 21, and oxygen saturation 96%. The patient's urine toxicology was positive for cannabinoids and cocaine. The patient's troponin level was unremarkable. The patient's electrocardiogram result was normal sinus rhythm (NSR). The patient was admitted to the hospital for COPD exacerbation/bronchitis. The patient was continued on treatment with steroids, bronchodilator, and antibiotic. Due to elevated D-Dimer level, the patient underwent a ventilation/perfusion (V/Q) scan to rule out pulmonary embolism (PE).

Based on the on the review of the medical record and literature, this patient did not need acute inpatient hospitalization. As per physical exam, the patient was in no acute distress (NAD). The patient's lung exam was described as clear. The patient's influenza screening test was negative. The patient's deep venous thrombosis (DVT) was negative. The patient's V/Q scan was negative for PE. The patient's clinical index of suspicion for PE was low prior to the V/Q scan. This patient remained stable after admission. The patient was afebrile, hemodynamically stable with no hypoxia. There was no clinical sign of pneumonia or pulmonary embolism. This patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was tolerating oral intake. The patient was stable to have been discharged home by day 2 of admission after a period in observation status. The patient's vital signs on day 2 of admission were: temperature 97.5, heart rate 98, respiratory rate 19, and blood pressure 138/84. The patient was tolerating oral intake. The patient's lungs were described as mild wheezing. The patient was stable to be discharged home on oral steroids, bronchodilators and oral antibiotics if clinically indicated with close follow-up in the outpatient setting.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.