Appeal type: Medical necessity
Decision: Upheld

Diagnosis COPD
Treatment Inpatient Hospital Stay.  The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for chronic obstructive pulmonary disease (COPD), asthma, hypertension, bipolar disorder, obesity, and medical noncompliance who presented to the emergency department with a two-week history of a cough associated with the production of green, thick mucus, chest congestion, back pain.
Her symptoms started after increasing the use of tobacco as well as crack cocaine and secondhand smoking, which occurred within several days prior to the date of admission. At the time of the initial evaluation, the patient denied any fever, chills, malaise, lack of appetite, chest pain, abdominal pain, nausea, vomiting, edema.
On the physical exam, the patient was afebrile, blood pressure was 116/75, respiratory rate 19, and oxygen saturation 93% on room air.
The patient was a well developed, well-groomed female in no distress. The airway was patent, respirations were nonlabored. The patient had diminished breath sounds bilaterally. There were no intercostal retractions.
The cardiovascular exam revealed a regular rate and rhythm, the pulse was normal without murmurs, rubs, or gallops. The abdominal exam was within normal limits.
Laboratory evaluation revealed that white blood cell count was 6.9, hemoglobin 11.6, hematocrit 35.9, and platelets 346. Sodium was 143, potassium 4.2, blood urea nitrogen (BUN) 6, creatinine 0.6, and glucose 96.
A Rapid Influenza Test was negative. A chest x-ray demonstrated stable findings of the heart being at the upper limits of normal in size and mild bilateral hyperinflation. An electrocardiogram (EKG) revealed normal sinus rhythm, no changes consistent with ischemia.
The patient was admitted to the hospital with the diagnosis of COPD exacerbation. In the hospital, the patient received treatment with bronchodilators via nebulizer, SoluMedrol, azithromycin.
Another admitting diagnosis was polysubstance abuse. It was mentioned that the patient smokes tobacco every day and uses cocaine weekly. Her other medical problems mentioned at the time of admission were hypertension, hyperlipidemia, and mood disorder. Those conditions were relatively stable. As a result of the treatment, the patient's clinical condition significantly improved, including the resolution of wheezing and improvement in her dyspnea.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary for this patient at the acute inpatient level of care.
Even though the patient presented to the hospital with shortness of breath and a cough with greenish mucus, she was afebrile, hemodynamically stable, had normal respiratory rate and oxygen saturation. The patient was in no acute distress. She received adequate treatment at the time of admission, and according to the progress note , the patient was afebrile, hemodynamically stable. Her respiratory rate and oxygen saturation were within normal limits on 2 liters of supplemental oxygen via nasal cannula. The patient had some wheezing, but no rales or rhonchi.
According to the Merck Manual Professional Version online,
"Mild exacerbations often can be treated on an outpatient basis in patients with adequate home support. Elderly, frail patients and patients with comorbidities, a history of respiratory failure, or acute changes in blood gas measurements are admitted to the hospital for observation and treatment. Patients with life-threatening exacerbations manifested by uncorrected moderate to severe acute hypoxemia, acute respiratory acidosis, new arrhythmias, or deteriorating respiratory function despite hospital treatment should be admitted to the intensive care unit (ICU) and their respiratory status monitored frequently." Specific to this clinical case, the patient had a relatively mild COPD exacerbation since she was afebrile, hemodynamically stable, had normal respiratory rate and normal oxygen on a small amount of supplemental oxygen. Reportedly, the patient utilized supplemental oxygen at home.
There was no obvious respiratory distress or hypoxemia. The patient's comorbidities, which included multi-substance abuse, bipolar disorder, and a history of medical noncompliance, could contribute to the patient's progress and jeopardize recovery. However, the severity of the patient's condition did not justify admission at the acute inpatient level of care. In general, the patient remained in stable clinical condition and had no signs of acute respiratory failure or any other concomitant condition that would justify the acute inpatient level of care.