Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD- chronic obstructive pulmonary disease .
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for asthma, hyperlipidemia, hypertension, schizophrenia, depression, and coronavirus disease (COVID) who presented to the hospital with complaints of shortness of breath that was attributed to an asthma exacerbation. Reportedly, she received albuterol treatment from Emergency Medical Services (EMS), which did not help much.
In the emergency department, the patient received treatment with an albuterol inhaler and prednisone with some improvement. At the time of the initial evaluation, the patient denied a fever, cough, chest pain, palpitations, nausea, diarrhea, or dysuria.
When the patient was seen by the admitting physician she was afebrile. The pulse rate was 77 beats per minute (bpm), respiratory rate 18 breaths/minute, blood pressure 141/89, and oxygen saturation 97% on room air.
The patient appeared to be in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. There was wheezing on the exam.
The patient was awake, alert, and oriented times three. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. There was no edema in the extremities.
Laboratory evaluation revealed that the white blood cell count was 5.4, hemoglobin 12.9, hematocrit 37.8, and platelets 196.
The sodium was 132, potassium 4.2, chloride 102, bicarbonate 21, blood urea nitrogen (BUN) 7, creatinine 0.8, glucose 119. The aspartate aminotransferase (AST) was 60, alanine aminotransferase (ALT) 56, and alkaline phosphatase 146.
The patient was admitted to the hospital with a diagnosis of acute asthma exacerbation. She was started on bronchodilators and prednisone.
In the hospital, the patient was seen by a pulmonologist who diagnosed the patient with a chronic obstructive pulmonary disease (COPD) exacerbation. The patient was recommended for treatment with corticosteroids and bronchodilators. During the hospital stay, the patient's clinical condition improved, and she was transitioned to outpatient care. 
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
It was determined that the patient had a COPD exacerbation and not an asthma exacerbation as was suggested by the admitting physician. Based on the nationally accepted standards of care, acute inpatient level of care is generally recommended for patients with severe underlying COPD with new or worsened signs or symptoms of COPD such as dyspnea, tachypnea, cough, sputum production. Admission at the acute inpatient level of care is also indicated for patients with COPD and high-risk active acute comorbidities such as pneumonia, dysrhythmia, heart failure, pleural effusion, pneumothorax, myopathy, rib fracture, or with new or worsened signs or symptoms of COPD. Admission at the acute inpatient level of care is also indicated in cases of COPD exacerbation associated with altered mental status, new worsening signs, and symptoms of COPD that persist despite observation care treatment.
Other clinical indications include acute respiratory failure requiring mechanical ventilation, new onset of hypoxemia that persists despite observation care treatment, worsening of pre-existing hypoxemia, or significant hypercarbia that persists despite observation treatment, or when patients need planned invasive surgical or diagnostic procedures requiring acute hospitalization and some other clinical conditions which were not relevant to this clinical case.
The review of the medical records clearly demonstrated that the patient did not have those circumstances listed above. Based on the progress note, the patient noticed an improvement in her symptoms. She denied a cough, fever, chest pain, palpitations. The patient was afebrile and hemodynamically stable. Her oxygen saturation was 98% on room air. There was no tachypnea. It is unclear why the decision was made to transition the patient to intravenous corticosteroids while her vital signs were stable and her respiratory status was improving.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. 
Overall, this patient remained in stable clinical condition. Her respiratory status was steadily improving. The patient did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.