The patient has a past medical history significant for tobacco abuse, sciatica, coronary artery disease, multiple sclerosis, and chronic obstructive pulmonary disease (COPD) who presented to the emergency department on with a chief complaint of worsening shortness of breath, difficulties breathing, and a feeling of "fluid" in the lungs when laying down. The symptoms started 2 days before the day of admission. In addition, patient complained of generalized weakness and a cough productive of clear mucus. In the emergency department, the patient's temperature was 102.4°F, blood pressure 135/77, pulse rate 124, respiratory rate 22, and oxygen saturation 93%.
In the emergency department, the patient received treatment with intravenous fluids, intravenous Solu-Medrol, several rounds of breathing treatment, intravenous magnesium, and Levaquin. An arterial blood gas (ABG) revealed that the potential hydrogen (pH) was 7.445, partial pressure of oxygen (PaO2) 51, PCO2 36, bicarbonate 24.3, oxygen saturation 85% on room air. The patient was admitted to the hospital with a diagnosis of acute exacerbation of the chronic obstructive pulmonary disease. In the hospital, the patient was treated with supplemental oxygen, bronchodilators, Prednisone, and Zithromax. The requested health service/treatment of inpatient hospital stay was medically necessary for this patient, since the patient developed acute respiratory failure with hypoxia due to COPD/asthma exacerbation, and also met sepsis criteria. Acute respiratory failure with hypoxia is a serious medical condition that requires treatment with supplemental oxygen as well as identification of the reason for hypoxemia with subsequent treatment of the underlying cause.
The presence of acute respiratory failure and possible sepsis increased the complexity of the services provided, and therefore, the patient's condition qualified for an acute inpatient level of care. Despite intense treatment provided in the emergency department, the patient still remained symptomatic, complaining of shortness of breath, and wheezing. This prompted admission to the hospital and initiation of treatment with bronchodilators, corticosteroids, and antibiotics, as well as close monitoring for signs of clinical deterioration of the acute respiratory failure. The health plan's determination is overturned in whole