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201906-118208

2019

Empire BlueCross BlueShield HealthPlus

Medicaid

Respiratory System

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Asthma
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
The patient did not meet the criteria for acute inpatient hospital stay for the COPD exacerbation. According to the documentation provided, the patient was hemodynamically stable, did not have any acute respiratory failure or acute respiratory distress requiring noninvasive ventilation; in addition, the patient's airway was not threatening requiring intubation with mechanical ventilation. Her mental status was intact. She was cooperative and communicative and was speaking in full sentences. Her oxygen saturation on room air at rest was 95-97%. Respiratory rate was 20 per minute which was within normal limits. Hemodynamically including blood pressure and pulse were normal; she was not in shock. The chest x-ray was clear and it did not suggest the presence of severe pneumonia, pneumothorax or pleural effusion. The cardiac workup was unremarkable for any acute coronary syndrome. This patient with acute COPD exacerbation should be considered as mild; therefore, the patient was not a candidate for inpatient hospital admission for management.

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