Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic respiratory failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


 
According to the medical records, the patient is an adult with Chronic obstructive pulmonary disease (COPD), chronic respiratory failure on home oxygen (4 liters per minute (L/min)), asthma, hypertension, tobacco and alcohol use admitted with main complaint of dyspnea on exertion and chest pain. He has bilateral rhonchi and decreased breath sounds. Chest x-ray showed stable findings of chronic obstructive pulmonary disease (COPD) /emphysema and mild bibasilar subsegmental atelectasis. He was treated for COPD exacerbation with intravenous (IV) methylprednisolone and albuterol/ipratropium bronchodilators. Other admitting diagnoses are acute on chronic respiratory failure, Alcohol (ETOH) abuse, elevated liver markers, and paroxysmal atrial fibrillation. The patient is non-adherent to prescribed home oxygen and bronchodilator therapy. Follow up note showed the patient had clinical improvement due to therapy with resolution of wheezing and was transitioned to oral prednisone. The request is for inpatient admission.

The patient had COPD exacerbation with increased dyspnea and acute on chronic respiratory failure. The patient has high risk of failure of outpatient therapy due to previous non-compliance. The patient required inpatient admission to complete therapy for potentially life-threatening conditions, such as COPD exacerbation.

"Acute exacerbations of COPD can be managed in an outpatient or inpatient setting depending on the severity. The assessment of severity is discussed in the previous section. Mild cases can be treated in the outpatient setting with bronchodilators, corticosteroids, and antibiotics. For moderate and severe cases, inpatient management is indicated. Hospitalized patients often require oxygen and bronchodilator therapy. Long-acting bronchodilators are typically used when the patient becomes stable and ready for discharge. Oral corticosteroids may be used; however, intravenous corticosteroids have not shown to be more efficacious compared to oral and instead may cause increased side effects. Intravenous corticosteroids may be considered if patients have a contraindication to oral intake (e.g., aspiration risk or continuous bilevel positive airway pressure (BiPAP) therapy). Antibiotics should be considered if there is suspicion for a bacterial infection. Oxygen therapy can range from a nasal cannula to mechanical ventilation depending on the severity of the exacerbation." (Agarwal, AK. et al. 2022).

"Acute exacerbations of COPD involve increased symptoms such as cough, dyspnea and sputum production. These exacerbations are associated with increased mortality as well as decline in lung function. Non-invasive positive-pressure ventilation (NIPPV) is the preferred method of ventilatory support in respiratory failure secondary to acute exacerbation COPD (AECOPD). Non invasive positive pressure ventilation (NIPPV) reduces work of breathing, improves oxygenation and ventilation and decreases both mortality and the risk of invasive ventilation."
(Lief, L., & McSparron, J. 2019).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.