Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She has a history of chronic obstructive pulmonary disease, chronic hypoxic respiratory failure on supplemental oxygen, pneumothorax status post right lung biopsy, and hypertension.  She presented to the ED (emergency department) with complaints of progressive shortness of breath, with associated decrease in O2 (oxygen) saturation from 80% to 68% on 2L (two liters) O2 (oxygen). She had minimal relief with inhalers. There were no associated factors.

The patient's VS (vital signs) were as follows:  Temperature 98.2, pulse 92, respiration rate 18, blood pressure 132/82, oxygen 98% on VM (Venturi mask). Her exam was unremarkable. Her labs were as follow: WBC (white blood count) 7.5, H/H (hemoglobin/hematocrit) 13.8/45.9, Na (sodium) 145, K (potassium) 5.0, CO2 (carbon dioxide) 29, BUN/Cr (blood urea nitrogen/creatinine) 17/.8.  Her VBG (venous blood gas) was 7.32/62/29/32.  Her troponin was 0.056. NT-proBNP (N-terminal pro b-type natriuretic peptide) was 12413.  Her CXR (chest x-ray) revealed right greater than left lower lobe infiltrate, bilateral effusions. Her EKG (electrocardiogram) revealed NSR (normal sinus rhythm),  new TWI (T-wave inversion).

The patient was treated in the ED (emergency department) with nebs, IV (intravenous) steroids and IV (intravenous) antibiotics.  ED (emergency department) notes show the patient was feeling much better after second re-evaluation.

The patient was admitted with acute on chronic respiratory failure.  Plan of care included trend EKGs (electrocardiograms) and cardiac enzymes, Solumedrol, neb, IV (intravenous) Lasix, and four days of antibiotics.

Day 2, the patient's vital signs were stable. Her O2 (oxygen) saturation was 89% on 4L (four liters). The plan was to continue antibiotics, nebs and prednisone.

Day 3, the patient was feeling better. Her O2 (oxygen) saturation was 93% on 3L (three liters) NC (nasal cannula). The plan was to continue steroids, nebs, and O2 (oxygen); changed to PO (oral) steroids. The plan was for discharge the following day.

Day 4, the patient had no complaints. Her O2 (oxygen) saturation was 92%.

No, the Inpatient admission was not medically necessary.
Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice.

This patient with a history of COPD (chronic obstructive pulmonary disease) and O2 (oxygen)-dependent chronic respiratory failure was admitted with acute on chronic respiratory failure.  Studies were remarkable for elevated troponin and elevated N-terminal pro b-type natriuretic peptide.  The patient's symptoms improved in the ED (emergency department) after second neb, steroids and antibiotics.  In addition to nebs and steroids, she was treated with empiric antibiotics for pneumonia.  She was changed to PO (oral) steroids on day #2.

Indications for hospitalization for patients with exacerbations COPD (chronic obstructive pulmonary disease) include high risk comorbidities, such as pneumonia, arrhythmia and congestive heart failure; marked increase in dyspnea; altered mental status; and inadequate response of symptoms to outpatient or an observation level of care. This patient had exacerbation of COPD (chronic obstructive pulmonary disease) that did not require ventilatory support.  She was hemodynamically stable and did not have altered mental status.  She did not have a high risk co-morbid conditions or an infection that required an acute inpatient level of care.  ED (emergency department) notes show the patient symptomatically improved while in the ED (emergency department).  She had not failed a lower level of care.  The inpatient admission was therefore not medically necessary.