Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld

The patient is a female with history of hypertension (HTN) who presented to the Emergency Department (ED) with complaints of increasing shortness of breath (SOB), cough with whitish phlegm, and right (R) sided chest pain for 2- 3 days. The patient reported increased pain with breathing. Vital signs at presentation were: temperature (T) 98.3 Fahrenheit (F), heart rate (HR) 99, respiratory rate (RR)19, blood pressure (BP) 133/71 millimeters of mercury (mm Hg), and oxygen (O2) saturations 93%. Lung exam revealed bilateral (B/L) wheeze and basilar crackles. Cerebrovascular system (CVS) S1 S2 was normal. The patient was awake and alert with a non-focal exam. 

The patient's labs revealed white blood cell (WBC) count 9.3, hemoglobin (Hb) 12.7 g, and electrolytes were within normal limits (WNL). Blood urea nitrogen (BUN) / creatinine 8/0.8, D-Dimer was 761, urine toxicology was positive for Cannabinoids and Opiates. Electrocardiogram (EKG) showed normal sinus rhythm (NSR). Troponin was normal. Brain natriuretic peptide (BNP) was normal. Arterial blood gas (ABG) was 7.38/36/100/21 on 3 liters.

Computed tomography (CT) angiogram was done. The patient was negative for pulmonary embolism (PE). It revealed right lower lobe (RLL) ground-glass opacity, consistent with pneumonia. Also, some scattered bronchiolar mucus plugging bilaterally.

The patient was treated with bronchodilators via nebulizer, steroids, ceftriaxone, and azithromycin. The patient was admitted to telemetry bed to rule out (R/O) myocardial infarction (MI). The patient was managed for chronic obstructive pulmonary disease (COPD) exacerbation related to pneumonia (PNA).  The patient was saturating 93% on room air (RA). On 2 liters nasal cannula (NC), saturations were 100%. The patient was seen by Pulmonary consult who recommended steroid taper, continue bronchodilators and Doxycycline. This patient remained stable after admission. She was tolerating orally (PO). She was discharged home with outpatient follow up.

The patient did not need acute inpatient hospitalization. The patient could have been placed in Observation status while diagnostic testing and treatment were continued. Observation status could be for up to 48 hours. The patient did not have any carbon dioxide (CO2) retention. Her pneumonia was mild. She was not hypoxic. She had low pulmonary severity index (PSI) and CURB 65 (confusion, uremia, respiratory rate, BP, age >= 65 years) score was zero. She remained hemodynamically stable after admission and was tolerating PO. The patient was stable to be switched to PO steroids, and PO antibiotics along with bronchodilators after a period under observation and then subsequently discharged home with close follow-up in an outpatient setting. 

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. An inpatient admission was not medically necessary.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.