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201908-120310

2019

United Healthcare Plan of New York

HMO

Respiratory System

Inpatient Hospital

Medical necessity

Upheld

Case Summary

This is a patient with a history of chronic obstructive pulmonary disease (COPD), asthma, hypertension and a known pulmonary nodule. She was admitted for dizziness, weakness, chills, shortness of breath, pain in her throat and difficulty along with an ongoing cough with sputum production and complaint of melena the day prior to admission. On admission, she was hemodynamically stable, was not in respiratory distress, had an oxygen saturation greater than (>) 90% on room air but had wheezing on auscultation. After treatment with intravenous SoluMedrol, antibiotics and short-acting bronchodilator nebulizations, she was noted to have an improvement in her symptoms. She was also evaluated and treated for anemia with intravenous iron. The health plan's determination is upheld. In the emergency room, the patient was not in respiratory distress, was not using accessory muscles, noted to have a respiratory rate of 16 breaths per minute but had wheezing on auscultation of the chest. The patient was given intravenous corticosteroids, antibiotics and Duoneb nebulizers. On admission, the patient was afebrile, hemodynamically stable, had a respiratory rate of 16 breaths per minute, had an oxygen saturation 92% room air and although on auscultation of his chest she continued to have wheezing she was not in any respiratory distress. In addition, she did not have evidence for hypercapnia, hypoxemia or cyanosis, a sustained heart rate greater than or equal to (¿) 100 beats per minute, she was alert, awake and oriented, was able to protect her airway and did not require ventilator support or supplemental oxygen. During the remainder of the hospitalization, the patient was hemodynamically stable, her oxygen saturation was reported >91% on room air and she was never in any respiratory distress nor have a respiratory rate ¿30. She was also evaluated for anemia for the initial complaint for melena the day prior to admission. She did not have active hemolysis or active bleeding, require invasive monitoring or emergent surgery, recurrent syncope or near syncope, cardiac arrhythmias, acute peripheral ischemia (eg, pulseless, cool, mottled, or cyanotic extremity), a low platelet count, acute renal failure or clinically significant signs or symptoms that are severe.

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