Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis, Chronic Obstructive Pulmonary Disease Exacerbation 
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was overturned.

This is a male patient with history of chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), hypertension (HTN), hyperlipidemia (HLD), atrial fibrillation (A Fib) status post ablation on anticoagulants, morbid obesity and obstructive sleep apnea. The patient was brought to the emergency department (ED) with complaints of shortness of breath (SOB) and productive cough with yellow expectoration of 2 days duration.

The patient denied chest pain. The patient was not on home oxygen (O2). The patient was treated with Decadron and nebulized bronchodilators. His vital signs at presentation to ED: temperature 39.3 C, respiratory rate 28, heart rate 97, and O2 saturations 92% on 4 liters nasal cannula. The patient was in moderate distress, and was noted to be diaphoretic. The lung exam revealed decreased breath sounds and scattered wheezing. Cardiovascular system was normal. There was extensive pedal edema. The patient's Labs revealed white blood cell count (WBC) 5.6K, Hb 13.7, electrolytes (Lytes) within normal limits (WNL) except Na+ 132, Brain Natriuretic Peptide (BNP) was elevated to 3400
International Normalized Ratio (INR) was 1.6 (patient was on coumadin) EKG Non-specific ST-T changes. ABG 7.42/41/67/93% on 4L NC PCR for Influenza A came back positive. Chest x-ray revealed no acute pathology noted. The patient was admitted to hospital for chronic obstructive pulmonary disease (COPD) exacerbation and fever. Initial findings indicated possible sepsis. In addition, findings were consistent with hypoxic respiratory failure and possible diastolic congestive heart failure (CHF). The patient was pan cultured and placed on intravenous (IV) antibiotics. The patient received IV steroids, bronchodilators and oxygen. The patient was given hydration and IV Lasix. An echocardiogram was done which revealed left ventricular ejection fraction (LVEF) 50-55%, dilated LA, thickened mitral valve and mild mitral regurgitation. After a period of medical stability the patient was discharged home.

Initial blood cultures drawn at admission came back positive for gram Positive Cocci and Gram Positive Rods. The patient was continued on antibiotics for possible sepsis (though contamination was also entertained as a possibility). This patient had multiple medical problems as outlined and had presented with fever and COPD exacerbation, Influenza and hypoxemic respiratory failure. Sepsis could not be definitively ruled out even though no clear focus was identified as the patient was febrile and had preliminary positive blood cultures and also had underlying valvular heart disease. Secondary bacterial infections are also a possibility in adults with Influenza.

It was safer to admit the patient and treat him as presumed sepsis rather than release him from the ED. The patient improved over next few days. Blood cultures were determined to be contaminants and the patient was subsequently switched to oral antibiotics and discharged home. There was no way to have predicted this as the patient was being evaluated in real time without the benefit of hindsight. The patient also qualified for home O2 and was discharged home on home O2. Based on above admission was appropriate.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for inpatient admission is substantiated.  The insurer's denial is overturned.