Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD exacerbation.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This patient with a past medical history significant for hypertension, depression, and ongoing tobacco abuse came to the emergency department with complaints of shortness of breath at rest, dyspnea on exertion, as well as a cough that started several days before her presentation.
The review of systems, obtained on admission, was negative for fever, chills, recent weight loss. The patient denied chest pain. The rest of the review of systems was unremarkable.
When seen by the admitting physician, the patient was afebrile, heart rate was 111 beats per minute (bpm), blood pressure 155/88, respiratory rate 22, and oxygen saturation 96% on room air.
Laboratory evaluation revealed that the white blood cell count was 9.9, hemoglobin 10.2, hematocrit 33.0, and platelets 183. The sodium was 140, potassium 2.6, chloride 99, bicarbonate 28, blood urea nitrogen (BUN) 2, creatinine 1.0, and glucose 119. Liver function tests were within normal limits.
A computed tomography (CT) angiogram of the chest demonstrated a 3 centimeter (cm) mass in the left upper lobe as well as a 1.1 cm nodule in the left adrenal and 2.4 cm nodule in the right adrenal. The patient was admitted to the hospital with an acute chronic obstructive pulmonary disease (COPD) exacerbation, mass in the upper lobe of the left lung, adrenal nodules, and ongoing tobacco abuse.
Interventional radiology was consulted for a CT-guided lung biopsy, which was performed. The patient received treatment with intravenous doxycycline, bronchodilators, and Solu-Medrol. Subsequently, the patient was switched to Prednisone.
The patient was discharged from the hospital in satisfactory clinical condition with consideration for a positron emission tomography (PET) scan for staging purposes, as well as follow-up with a pulmonologist and hematologist/oncologist. At issue is the medical necessity of an inpatient stay.
The inpatient hospital stay was not medically necessary for this patient. According to the medical records, the patient had a mild COPD exacerbation without any evidence that the patient had severe COPD at the baseline. The admitting physician stated that the COPD exacerbation was mild. There was no evidence that at the time of the presentation the patient had pneumonia, pulmonary embolism, or heart failure. There was no evidence of significant carbon dioxide (CO2) retention leading to altered mental status. There was no need for mechanical ventilation. The patient's clinical condition improved within the first 48 hours of hospitalization. According to the progress notes, the patient was afebrile, the heart rate was 89 bpm, the blood pressure and the respiratory rate were within normal limits.
It was indicated that the patient was awake, alert, and oriented times () 3, not in acute distress. On the pulmonary exam, the patient's lungs were clear to auscultation bilaterally without wheezing, rales, or rhonchi. At that time, the patient was waiting for a CT-guided lung biopsy, which in general is an outpatient procedure.
Taking into consideration all of this information, the patient's clinical condition, including respiratory status, significantly improved within the first 48 hours of the hospitalization. The procedure performed in the hospital did not require admission at the acute inpatient level of care.
Overall, the patient remained in stable clinical condition and her symptoms were improving. She did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 

This coincides with Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 23rd Edition criteria for Chronic Obstructive Pulmonary Disease. Based on these criteria, the admission at the acute inpatient level of care is generally recommended for patients with severe underlying COPD with new or worsened signs or symptoms of COPD such as dyspnea, tachypnea, cough, sputum production. The admission at the acute inpatient level of care is also indicated for patients with COPD and high-risk active acute comorbidities such as pneumonia, dysrhythmia, heart failure, pleural effusion, pneumothorax, myopathy, rib fracture, or with new or worsened signs or symptoms of COPD.
Admission at the acute inpatient level of care is also indicated in cases of COPD exacerbation associated with altered mental status, new worsening signs, and symptoms of COPD that persist despite observation care treatment. Other clinical indications include acute respiratory failure requiring mechanical ventilation, new onset of hypoxemia that persists despite observation care treatment, worsening of pre-existing hypoxemia, or significant hypercarbia that persists despite observation treatment, or when patients need to plan invasive surgical or diagnostic procedures requiring acute hospitalization, and some other clinical conditions that were not relevant to this clinical case. The review of the medical records demonstrated that the patient did not meet those criteria. Specifically, there was no urgency to perform the biopsy while the patient was still recovering from the acute COPD exacerbation.