Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease). 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 
 The denial is upheld. 

This patient has a history of (H/O) chronic obstructive pulmonary disease (COPD)/ congestive heart failure (CHF), diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), and Morbid Obesity. The patient presented to the hospital with complaints of intermittent midsternal chest pain (CP) radiating down the L (left) arm, shortness of breath (SOB), and cough with yellow sputum. The patient also had some abdominal pain and diarrhea for 5 days and had been admitted to another hospital the previous week, where he was treated with antibiotics (Abx) for bronchitis. 

Vital signs at presentation: Temperature 98.5 degrees F (Fahrenheit), Heart Rate 81, Respiratory Rate 18, Blood Pressure 123/89, oxygen saturation 93 % on Room Air. The patient was in no acute distress (NAD). A lung exam revealed bilateral (B/L) wheezing. Cardiovascular system (CVS) S (sinus)1 S2 N (normal). No myocardial infarction. The patient was awake and alert. 

The patient was treated with intravenous (IV) steroids, bronchodilators (BD) and 1 dose of IV Rocephin. 

Labs revealed WBC (white blood cell count) 7.6K (thousand), Hb (hemoglobin) 11.8, Electrolytes within normal limits (WNL), and BUN (blood urea nitrogen) /Creatinine WNL (within normal limits). The chest x-ray revealed no acute infiltrate. An ECG (electrocardiogram) showed no acute ST (interval on an ECG) -T (interval on an ECG) change and Troponin was negative. Venous Blood Gas (VBG) pH (potential of hydrogen) 7.35/ PCO2 (partial pressure of carbon dioxide) 51. The patient was placed on bilevel positive airway pressure (BIPAP) 16/6 40 %. The patient was admitted to hospital with COPD exacerbation. 

After admission, per History and Physical, the patient was in no distress and was ambulating in the hallway. He was afebrile, Heart Rate 70, Respiratory Rate 18, Blood Pressure 155/86 and oxygen saturation 94% on Room Air. The patient was not using accessory muscles to breathe. Lung exam showed bilateral wheezing. He was continued on oral (PO) steroids and Bronchodilators after admission. No antibiotics were given. The patient was using BiPAP only at night for obstructive sleep apnea (OSA). Deep vein thrombosis (DVT) study was also negative. 

The patient remained stable after admission. He was afebrile and hemodynamically (HD) stable. There was no pneumonia (PNA) on the CXR (chest x-ray). No signs of Ischemia on the ECG and Cardiac enzymes were also normal. He was ambulating and tolerating oral food and fluids. He was treated with oral medications and bronchodilators via nebulizer. He was stable to be discharged home after a period under observation. Observation could have been for up to 48 hours. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission services is not substantiated.