Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic obstructive pulmonary disease.
Treatment:  Inpatient admission.

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

The patient has a history of chronic obstructive pulmonary disease (COPD) and asthma.  The patient presented to the emergency department (ED) with complaints of respiratory distress.  The patient stated that they had worsening shortness of breath for 4 days.  The patient's vital signs in the ED were: blood pressure (BP) 162/103, pulse (P) 94, respiratory rate (RR) 38, oxygen (O2) saturation 89% (percent) on room air (RA).  The patient was placed on a non-rebreather (NRB) mask.  The patient was noted to be using accessory muscles during respiration.  The lung exam revealed bilateral wheezing.  The patient's labs revealed a white blood cell (WBC) count of 5.9, hemoglobin (Hgb) 13.7, hematocrit (Hct) 40, and international normalized ratio (INR) 1.8.

The patient's chest x-ray (CXR) showed hyperinflated lungs with some emphysematous changes.  No acute infiltrates were noted.  The patient's arterial blood gas (ABG) results were: 7.43/41/184/27.  The patient was treated with Solumedrol intravenously (IV), IV magnesium, Doxycycline, and DuoNebs.  The patient was admitted to the hospital with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) exacerbation.  The patient was continued on IV steroids and bronchodilators.  The patient was also given Thiamine and Folate as part of the Clinical Institute Withdrawal Assessment (CIWA) protocol. 

The patient improved dramatically with treatment in the emergency department (ED).  As per the history and physical, the patient's vitals were Temperature 98.8 degrees Fahrenheit (F), Respiratory Rate 19, Pulse 88, Blood Pressure 162/103, and Oxygen saturation 100%.  The patient was not in distress and was conversing fully.  The patient's lung sounds were equal bilaterally with mild wheezing.  The patient was continued on intravenous (IV) steroids and bronchodilators.  Therapy was initiated with inhaled corticosteroids (ICS)/long-acting beta agonists (LABA) and long-acting muscarinic antagonists (LAMA).

The patient continued to improve.  The next day, the patient was afebrile with stable vital signs. The patient was in no acute distress.  Lungs were clear.  Cardiovascular exams revealed normal heart sounds in S1 and S2.  The patient's abdomen was soft.  The patient was alert and oriented to person, place and time.  The patient's neurologic exam was non-focal. 

Antibiotics were discontinued as the patients computed tomography (CT) scan did not reveal any infiltrates.  The patient was switched to an oral (PO) steroid taper and was not hypoxic.  The patient's oxygen saturation was 99% on Room Air.  The patient was continued on prescriptions for LABA/ICS/LAMA and bronchodilators as needed (PRN) via nebulization.  The patient was medically cleared for discharge.

This patient did not need acute inpatient hospitalization.  The patient could have been placed in observation status while diagnostic testing and treatment were initiated.  Observation could be for up to 24 hours. During this time diagnostic studies could have been done and treatment initiated. The patient improved rapidly with treatment and was placed on oral steroids. The patient could have been placed in observation instead of admitting to inpatient.
The patient remained stable after admission. Steroids were tapered. Doxycycline was discontinued, as there was no pneumonia (PNA).

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 the inpatient admission is not substantiated.