Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic obstructive pulmonary disease (COPD) 
 
Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission. The denial was upheld.

This patient is a female with a history of asthma, obesity, hypertension, chronic obstructive pulmonary disease (COPD) and hyperlipidemia who presented to the Emergency Department (ED) with complaints of shortness of breath accompanied by some wheezing. She reported having thick yellow /green sputum.  The patient had been traveling and had not been taking her COPD medications.  The patient was prescribed oral antibiotics for possible community acquired pneumonia (CAP), but had not filled her prescriptions.

At presentation to the ED, the patient was afebrile.  Her temperature was 98.2F, the blood pressure was 137/81, respiratory rate was 20 and oxygen saturations were 90% on room air. The patient was noted to be ambulating in the ED.  A lung exam revealed wheezing in both lower lobes.

The patient's white blood cell (WBC) count was 10.1K.  Electrolytes were within normal limits.  A chest x-ray showed cardiomegaly, but no lung parenchymal abnormalities.  Her thyroid-stimulating hormone (TSH) was elevated, as was the proBNP (brain natriuretic peptide).  The patient was treated with Duo Nebs, intravenous (IV) steroids and IV antibiotics - Ceftriaxone and Azithromycin.  The admitting diagnosis was COPD exacerbation secondary to CAP.

This patient did not need acute hospitalization.  As per the ED note, the patient was alert and oriented x3.  She was ambulating to the bathroom.  The patient's vital signs were stable. On the day following admission the patient's oxygen saturations were 97% on room air.  She was ambulating and tolerating oral intake.  As per clinical documentation, even though her proBNP was elevated, the patient did not have any signs of congestive heart failure.  The patient's echocardiogram revealed an ejection fraction (EF) of 30-35% and left ventricular hypertrophy.  The patient was seen by Cardiology and oral Carvedilol and Aldactone were started.

This patient did not have any signs of pneumonia. A chest x-ray showed no pulmonary infiltrates.  The patient was afebrile and the WBC count was normal.  The patient was stable for discharge after initial evaluation and treatment in the ED.  The patient's CURB 65 score was Zero.  The patient had improved with treatment in the ED.  She was afebrile and hemodynamically stable.  The patient's COPD was also not that severe.  The patient's oxygen saturations were acceptable.  The patient was ambulatory.  She was tolerating oral intake and was stable to be discharged home after evaluation and treatment.  The patient could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient remained stable after admission and was stable to be discharged home on oral medications - antibiotics and bronchodilators, as well as cardiac and thyroid medications with close follow-up in an outpatient setting.  

The prior denial is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.