Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Chronic Obstructive Lung Disease/COPD
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is a case of a patient admitted to the hospital for a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. The patient presented with one day history of dyspnea and in the emergency department was treated with DuoNeb, steroids, and magnesium. The patient was found to have an oxygen (02) saturation of 92 to 94% on room air. There was mild expiratory wheezing. There was no diagnosis of COPD in the history, but he was admitted for suspected diagnosis of COPD exacerbation. Vital signs demonstrated temperature 98.5 Fahrenheit, pulse 121, respiratory rate 20, and blood pressure 162/92. Physical exam showed no altered mental status or respiratory distress. The complete blood count was normal. Calcium was 10.5 and otherwise the basic metabolic panel was normal. Chest x-ray showed clear lungs without consolidation. D dimer (a test used to rule out a blood clot) was negative. Troponin was negative. An electrocardiogram showed normal sinus rhythm. Venous blood gas showed potential hydrogen (pH) 7.316, partial pressure of carbon dioxide (PC02) 62 and bicarbonate 26. The patient was treated with albuterol, ipratropium, and prednisone with improvement in clinical symptoms. The patient was able to be discharged on tiotropium and was arranged to have pulmonary clinic follow-up upon discharge. 

Medical necessity of the inpatient stay has not been established.

According to Up-to-date, 2020: "Triage To Home Or Hospital - An important step in the initial evaluation is to determine whether the patient needs hospitalization or can be safely managed at home. More than 80 percent of exacerbations of COPD can be managed on an outpatient basis, sometimes after initial treatment in the office or emergency department. If the exacerbation appears life-threatening or if there are indications for ventilatory support (e.g., hypoxemic or hypercapnic respiratory failure), the patient should be admitted to the intensive care unit as quickly as possible.
Other criteria that might lead to a decision to hospitalize the patient have been proposed in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and include:

1) Inadequate response to outpatient or emergency department management 2) Onset of new signs (e.g., cyanosis, altered mental status, peripheral edema) 3) Marked increase in intensity of symptoms over baseline (e.g., new onset resting dyspnea) accompanied by increased oxygen requirement or signs of respiratory distress 4) Severe underlying COPD (e.g., forced expiratory volume in one second [FEV1] less than or equal to 50 percent of predicted) 5) History of frequent exacerbations or prior hospitalization for exacerbations 6) Serious comorbidities including pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, or liver failure 7) Frailty 8) Insufficient home support"

The patient in this case did not require ventilatory support, have hypoxemia or hypercapnic respiratory failure. The patient did not have an inadequate response to outpatient or observation treatment, cyanosis, altered mental status, peripheral edema, increased oxygen requirement, severe COPD by forced expiratory volume (FEV1) testing, history of frequent exacerbations, pneumonia, arrhythmia, heart failure, liver failure, renal failure, or diabetes. There was no frailty or insufficient home support. 

Although the patient had needs best addressed in the hospital setting, the monitoring, diagnostic workup, and therapeutic interventions prescribed could have been safely administered at a lower level of care.