Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, shortness of breath, chest tightness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented to the emergency department for cough, shortness of breath, chest tightness and wheezing of one-week duration.  She was called in steroids by her primary care doctor and had finished the course two days prior to the presentation to the emergency room.  

The patient's temperature was 98.4, pulse 67 and regular, blood pressure 173/77, respiratory rate 25 per minute, and oxygen saturation on room air at rest was 90%.  She has a past medical history of very severe COPD (chronic obstructive pulmonary disease), tobacco abuse and asthma.  Her chest examination was pertinent for diffuse bilateral wheezing.  Laboratory data was pertinent for normal x-ray, normal EKG (electrocardiogram) with WBC (white blood cell) count of 6.45, serum potassium of 3.1, and influenza A screen positive.  

The patient was admitted to the hospital for acute COPD  (chronic obstructive pulmonary disease) exacerbation.

No, the Inpatient admission was not medically necessary.

Based on the clinical examination, the patient would be considered as acute COPD (chronic obstructive pulmonary disease) exacerbation triggered by Influenza A infection.  The patient was known to have severe COPD (chronic obstructive pulmonary disease).  Her vital signs were stable. The patient was not febrile. Her heart rate was 67 per minute. Her respiratory rate was on the higher side, at 25 per minute. The oxygen saturation was 95% on room air at rest.  Blood pressure was slightly elevated. Laboratory data were unremarkable. Chest x-ray was unremarkable. The patient's blood pressure had stabilized and improved to 153/61. The respiratory rate improved to 18 per minute.  This was after the patient had received initial intervention, including systemic steroids and bronchodilator therapy/nebulizers in the emergency room, along with IV (intravenous) fluids.  The patient was stabilized hemodynamically, including the improvement of blood pressure pulse and respiratory rate.  

There was no documentation of acute hypoxic respiratory failure requiring high-flow oxygen or noninvasive ventilation such as CPAP (continuous positive airway pressure) or BiPAP (bilevel positive airway pressure), or altered level of consciousness due to hypercarbia. Arterial blood gases were not performed. Venous blood gases were performed, which were within normal range.  The patient did not have any features suggestive of severe sepsis or septic shock requiring vasopressor support. There was no evidence of end-organ injury, such as development of acute kidney injury due to severe respiratory failure requiring monitoring of kidney function including hemodynamics monitoring and aggressive volume support.  The patient was ambulatory, communicative, and was not in respiratory distress after couple of hours of emergency department (ED) management and stabilization.  The patient remained stabilized hemodynamically throughout the admission, as documented by the nursing note, physician notes and the vital signs.  Based on the clinical information provided, the patient could have been safely and effectively managed at a lower level of care.