Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld. 

The patient has a history of chronic obstructive pulmonary disease (COPD) on home oxygen (O2) 4 liters (L) by nasal cannula (NC), pulmonary embolism (PE) on NOAC (new oral anticoagulants), schizophrenia and bipolar disorder. The patient also has chronic lower extremity (LE) stasis ulcers. He was brought to the emergency department (ED) at the recommendation of his home health aide, who felt the patient was more short of breath (SOB) and also complained of some worsening of LE cellulitis/ulcers along with pain. As per reports, the patient's O2 saturations at home on 4 liters nasal cannula (NC) ranged from 76-89% (percent). Vital signs (V/S) at presentation to ED were temperature (T) 98, heart rate (HR) 97, respiratory rate (RR) 15, blood pressure (BP) 125/70 mm Hg (millimeters of mercury), O2 saturations 74%. The patient however did not report any respiratory distress. He said he was at his baseline. Shortly afterwards, V/S were T 98, HR 88, BP 115/72, and O2 saturation was 86%. The patient was in no acute distress (NAD). Labs revealed white blood cell count (WBC) 3.5K (thousand). Hemoglobin (Hb) was 15.7 and electrolytes were essentially normal. Brain natriuretic peptide (BNP) was 89, and venous blood gas (VBG) was 7.34/62/34.  

Chest X-ray (CXR) revealed chronic interstitial changes. There was no acute pathology. CXR was essentially unchanged. Ultrasound of the lower extremities showed no venous insufficiency. The patient was treated with intravenous (IV) antibiotics, pain medications and bronchodilators in the ED. The patient was placed on bilevel positive airway pressure (BIPAP) for some time. As per note from ED, the patient was substantially improved. O2 saturation was 91% on 6L NC.

The patient was admitted to the hospital for COPD and LE cellulitis. At the time of the history and physical (H&P), the patient denied any SOB, chest tightness, fever or chills. Lungs had good air entry bilaterally. Occasional end expiratory wheeze was heard. Chronic stasis ulcer noted over LE. No erythema. Granulation tissue noted. The patient remained stable after admission. As per H&P, COPD was not in exacerbation. LE stasis ulcers. The patient was feeling better. Afebrile and hemodynamically (HD) stable, lungs good air entry.

The patient was saturating 90% on 5L NC. This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was at his baseline. O2 saturations were close to baseline a few hours after presentation. The patient denied any symptoms of COPD exacerbation. The patient's LE ulcers were chronic. No infection noted. The patient was afebrile with normal WBC. No pneumonia (PNA) on CXR. Vascular surgery follow-up arranged as outpatient.

This patient could have been discharged home after a period in observation status during which diagnostic testing and treatments could have been initiated. Observation could be for up to 48 hours. The patient had stabilized long before that and was discharged on the day after admission in about 24 hours. The patient was to continue his supplemental O2. O2 saturations were close to baseline. The patient was to continue maintenance COPD meds and follow up with vascular surgery in outpatient setting. 

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

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