Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD) 
Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission 

The denial is upheld. 

The patient was then a female with history of sarcoidosis, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), schizophrenia, and obesity status post bariatric surgery.  The patient presented to the hospital with complaints of chest pain and shortness of breath (SOB). At presentation to the Emergency Department (ED), the patient's vital signs were: temperature (T) 98.4 F, heart rate (HR) 90, respiratory rate (RR) 20, blood pressure (BP) 131/81 and oxygen (O2) saturations 96 % on room air (RA). On physical exam, the patient was awake and alert, and the patient was in no acute distress (NAD).  The patient had minimal wheezing noted in her lung exam but had no respiratory distress; cardiovascular exam was unremarkable. The patient's lab showed white blood cell (WBC) count of 5.3 K and hemoglobin of 13, and the patient's electrolytes were within normal limits. The patient's chest x-ray showed cardiomegaly and mild congestion. The patient's troponin was negative and her electrocardiogram (EKG) showed normal sinus rhythm (NSR) with no acute changes. The patient's influenza screening was negative. The patient was treated with intravenous (IV) steroids, bronchodilators via nebulizers and oral pain medications in the ED.  The patient was then admitted to inpatient status for chronic obstructive pulmonary disease (COPD) and possible sarcoidosis. As per the patient's admitted note, History & Physical, the patient was afebrile and hemodynamically stable; the patient's peak expiratory flow (PEF) was 270; the patient's lungs were clear with some decreased breath sounds; the patient's arterial blood gas (ABG) on room air was  pH 7.35, pCO2 39, pO2 76.  

As inpatient, the patient was continued on steroids, bronchodilator, antibiotics and oral pain medications.  The patient remained afebrile and hemodynamically stable. The patient's physical exam was unremarkable.  The patient was in no acute distress (NAD).  There was no respiratory distress.  The patient was tolerating oral intake. The patient's white blood cell (WBC) count was stable at 6.1 K. The patient's computed tomography (CT) chest showed scarring and bilateral pulmonary nodules that were consistent with her previous CT scan. The patient was started on a steroid taper.

Based on the review of the medical record and the literature, this patient did not need acute inpatient hospitalization.  The patient could have been placed on Observation status while diagnostic testing and treatment initiated.  The patient's chronic obstructive pulmonary disease (COPD) was mild.  The patient was in no respiratory distress and was tolerating oral intake. The patient's oxygen saturation on room air was 96% and did not need supplemental oxygenation. The patient's chest x-ray and follow-up computed tomography (CT) scan of the chest was not suspicious of pneumonia or any acute findings. The patient's CT scan was unchanged from her prior CT scan several months ago; the patient's sarcoidosis was stable. The patient was afebrile and had no leukocytosis. The patient was stable for discharge on oral steroid taper, bronchodilators and pain medications and oral antibiotics if clinically indicated after a period in observation. Thus, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.